I'm John Ransom. I'm here with Caitlin and Tony from the Lumexa management team. Just a couple of comments. Number one, it's a big day in radiology. Their competitor, Flash Numbers, announced a big deal. These guys, Flash Numbers. I'm all excited. The sector we've done a lot of work on has some new news today. That's one. Two, this is a new IPO. The company came public in December of 2025 and just announced their outlook for the year and their fourth quarter results, which were bang on our model. Well, that's good. Thirdly, what I think is interesting is now that we have two models in the market, I think there's a healthy debate about owning versus renting technology, growth strategy, and the like.
We think a thoughtful compare contrast is kind of a useful thing to do in looking at the space. With that, Caitlin and Tony will lead off, and we'll probably have some time at the end for Q&A. Thank you.
Yes. Thank you so much, John, thank you all for taking time out of your day. As John said.
Do you wanna that mic there, or you can hold this?
Supposedly this works.
Oh, you. Oh, okay. Yeah.
I'm on.
You got it.
We are a relatively new IPO.
I know you are.
We know that some of you might be newer to our story. We also have new information to share. What we're gonna attempt to do in 20 minutes or less is give an overview of who we are, deep dive into some of the incremental information that John has actually helped us really think through, namely transparency, more transparency around how our hospital JV partnerships work and the financials around them, and then obviously diving into our 2025 results and our guidance for 2026. In the spirit of that, I'm going to try to go very quickly through some of the introductory slides. These are the key highlights. Radiology is a dynamic and growing industry. We are already the second-largest platform. We've got great joint venture relationships.
We believe in a technology that will transform the industry. We have a partnership approach that we are happy to talk through. We have a great team. There's a lot of exciting opportunities for growth through same-site growth, de novo, and M&A. Before we get into that, this is our team. My name's Caitlin Zulla. I am honored to serve as the CEO of Lumexa Imaging. Tony will introduce himself as he begins to speak. One of the things we have in common is a history in the ASC space. Ambulatory surgery centers have a lot of parallels to outpatient imaging, as you'll see in both the health system partnerships, how they help our health systems create proactive outpatient ancillary strategies, and then, of course, the four-wall box economics. As I mentioned, Lumexa Imaging is the second-largest platform in the United States.
We have 189 centers. They are located in primarily strong MSAs that have 2 times the average population growth rate. Think markets like Dallas, Atlanta, Charlotte, Denver. That affords us a very strong commercial payer mix. We provide both advanced and routine imaging. Advanced is your MRI, your CT, your PET. Routine is your X-ray, your ultrasound, your diagnostic and screening mammo. That's because we wanna provide everything via one-stop shop to referring physicians, and you'll see we continue to advance our growth in advanced imaging, which is driving our strong performance. We have grown through de novo and acquisitions. We announced this morning that we've completed nine de novo in 2025, a company record. We've already opened one this year, and then there's certainly ample opportunity for M&A in this space as well.
Sometimes the pictures are the thousand words. If you wanna see what a center looks like, incredibly convenient. You can drive right up. You can get some of the economics and stats around how our centers work. We can open up a new de novo for $4 million in CapEx. That's if we own 100%, half of that being equipment leases. As we talk about why de novo are such an exciting flywheel for us, it really is, you know, the light capital footprint and the strong returns we're able to get. Some metrics to the left. This is our true north, our patient provider satisfaction. Really proud to have a patient NPS of 91. You can see the operational highlights on the right.
Namely, we are 99% in-network, we have 63% of our revenue comes from commercial payers, 63% of our revenue comes from that advanced imaging, which is about 35% of our volume. You can see our partnerships with amazing health systems on the right. We'll talk a bit more about that in a couple of slides. Some updated metrics reflecting preliminary results through the end of 2025. Tony will talk more about that in a few slides. This is a reminder of our modality revenue mix, volume mix, and payer mix. Most of this I've hit, but it's helpful. Sometimes people wanna ask questions around the payer mix specifically. 63% commercial, 19% Medicare. That includes both fee-for-service Medicare and MA, all included in that bucket. You can see the rest, including 3% Medicaid.
One of the things I love so much about the company is how we provide value across all of the stakeholders that we serve. Patients love the care they receive from us, same-day access, extended hours. We do everything we can to give them answers, and that drives the patient NPS of 91. We call on over 120,000 referring physicians, so our sales force of 120 reps. In the sake of time, I won't drain why referring physicians love to work with us, but happy to answer questions offline. We work with eight joint venture partners, UPMC being our newest one. We'll talk a little bit more about why they love working with us and how that works in the next slide. We drive value because we are lower cost.
We are 60% lower cost than Hospital Outpatient Departments. We are reimbursed under a separate fee schedule, the Physician Fee Schedule. When you think about site of service, there is no risk of that in our business 'cause, again, we're already being reimbursed at the lower cost site option and 60% cost savings in areas, of course, to the payers and to our patients. In the imaging industry. It's a $140 billion TAM growing at a 4% CAGR. Outpatient imaging is a $33 billion TAM growing at a 7% CAGR. Much of that driven by the site of service trends that, of course, you've seen across the industry, including in ambulatory surgery centers. We've talked through the fact that we focus on advanced imaging.
There's a lot of words on the slide that tell you why, but first of all, advanced imaging is growing 2 times the rate of routine, and it reimburses at about a 3 times higher multiple per revenue, driving revenue and margin. Why is it growing so much faster? Well, it's all the things you know. Aging population, increasing chronic conditions, more complex care, more proactive screening mandates, and then of course, novel treatment paradigms, your cancer care, your Alzheimer's care, all that requires advanced imaging. We fulfill the Quadruple Aim. We, you know, obviously, are convenient, very convenient for our patients, again, driving that patient NPS. We talked about the 60% lower cost savings, so we are the lower cost and high quality.
This graph in the to the right-hand side is one of the ones that I get most excited about. It is an incredibly fragmented industry. When you think about opportunities for growth, there's 6,000 IDTFs out there in the world and an incremental 8,900 HOPDs. RadNet is the biggest. This is obviously dated. They just announced they're at 419 centers this morning. We're at 189 now, and together we are less than 9% of the overall IDTF population, less than 4% of the HOPDs, and over 75% of the remaining 6,000 sites are in sites of five or fewer. It's very sub-scaled and fragmented. Health systems.
Health systems are excited to work with us because many of them are thinking through how can they proactively diversify their outpatient ancillary revenue. They've done it with ASCs and urgent cares and PT. Not very few have done it with imaging. We provide them that answer. When we engage with them, it's not a simple, "Let's decant your higher reimbursing HOPD to a lower cost center." It is all about how do we extend your market share. We do that through our sales team. We typically bring in 75% of the patients outside of the health system's existing patient referral landscape, so again, expanding their impact. What they bring to us is typically managed care experience. They do bring some volume.
They share capital, that $4 million in CapEx that I talked about at de novo, we would share that pro rata. Typically, it's 51 them, 49 us, of course, they've got incredible brands in their market. This is a typical JV structure. You can see that how it all works. We typically have 49% ownership. They have 51. That allows them to take first chair in the managed care contracting. Managed care contracting is done at the JV entity number level, it is a shared contract. It's not one side owns it versus the other. The JV has the contract. We bill a global bill, that is the technical and the professional. We have a contract with a read group to do the reads, you can see we also get a management fee.
Net of that, we share the EBITDA according to our pro rata split. You can see what are our responsibilities in the JV partnership. We do the employment, we handle all of the staffing, the capital strategy, the equipment purchasing, the tech platform, the revenue cycle, the sales and marketing, and then we depend on the JV partner, typically for the managed care contracting and then some physician alignment. We've received feedback that it would be helpful to better understand how this all flows through our financials because we do not consolidate anything where we have a minority interest. When we're owning 49%, we do not consolidate that. There's no NCI in our income statement. I'm gonna share the next slide to Tony. Once you see it, you'll know why.
It will help you triangulate how to get more visibility around the JVs in our S-one. See? That's a CFO slide right there.
Yeah.
Wow.
I need.
Inspired by you, John.
I'll just spend about 47 minutes walking through each and every number on here if that's all right with everybody. This is really intended. Our slides are posted on our website. This is intended as an example. Feel free to look at it in more depth, see if it helps in terms of understanding how the joint ventures are reflected within our numbers and the numbers that we disclose in our S-one and that will be recurringly in our 10-Ks and Q's. The bottom line is operating through a joint venture is the same fundamentally for us. We just don't consolidate it. It's not in our consolidated revenues and expenses, it's not in our assets and liabilities, there is a lot of visibility into what's going on in that book of business if you know where to look.
This is an example of a few points that are in our filings, and we'll strive to put them in more convenient, you know, capsule location in one place in our filings because this is a good story for us for you to know everything there is to know about what's going on in these JVs. For example, the debt level at these joint ventures. That's not on our balance sheet, but it's only $71 million. If it were on our balance sheet, our pro rata share would be enough to move our secured lab-leverage ratio by about 0.15x . It's not there, it's not on our books, but you can see what it is, and it's not a scary number.
Other things, if you look down, up, and down the income statement, their revenues and expenses are not in ours. You have visibility into them because we disclose them. About three-quarters of them are audited because we have a very large joint venture with Baylor Scott & White Health. Under SEC regs for something that big, you have to get a full audit of their financials. Those are right behind ours in our filing, and you can always go see exactly what's going on with a full set of financials and footnotes for them. Importantly, how does this flow through to us?
I've always found it useful in structures like this, and I used to work at USPI years ago, who had a lot of this type of business and this type of structure also, just to compare what we're recording as earnings to what we're getting out of those businesses in cash. That number is sitting right on our consolidated financial statements, equity and earnings on our income statement, and distributions from investments and unconsolidated affiliates on our cash flow statement. We're gonna try to marry this up in a little more digestible slide going forward, but I hope a deep dive here gives you the idea that this is really visible, and we want it to be, and we'll keep doing it different ways as needed to make sure that that's clear.
Another point about our joint ventures is, as the manager of these joint ventures, which means we basically do all the work, versus the health system bringing contracting clout to the table. We're basically doing everything else. You know, we're hiring and furnishing the employees, providing IT services. We design where the sites are gonna be. We're responsible for getting them open. We get a management fee. If you look at down at the bottom of this slide, you'll see at the JV level on the left side of the slide, they're paying us a management fee. We record that as income on our side over on the right. We have some expenses at our level to do those services, but we do earn a margin on that management fee, which is, I think, common in a healthcare business.
In addition, the JVs, you know, lease employees from us and secure certain IT and other services that happen at their sites from us. The accounting rules require us to gross that up and show it as revenue from the sites. It leads to us having a lot of revenues in our management fee and other categories that are zero margin, where they're just pass-throughs. That's about two-thirds of what's on that line item. If you're trying to look at us and see how revenue increases are gonna translate to profit, that zero margin piece is an important part to keep in mind. Maybe a little bit more nerdy than most people wanna get, but we're eager for this information to be out there for you to use.
Thank you. All right. In the spirit of time, because we are at a growth conference, I will hit our growth algorithm, then happy to answer additional questions about it offline or in the next session. As we think about growth, the core of our growth in terms of the numbers we put out is same-store revenue growth. That is driven 2/3 by volume, 1/3 by rate. Rate is about 1/2 acuity mix, so doing more advanced, then the 1/2 is rate increases from payers. We also assume in our numbers that we've put out that we will open eight to 10 de novo a year. We did 9 this year. We feel strongly that we'll hit those numbers. JV partnerships will make that possible.
Tony, in his section, will talk a little bit about how we operate in two segments. We have the outpatient imaging segment that is growing 7%-9%, and then an inpatient kind of pro- fee segment that we are intentionally growing less, about 5%. That's what gets us to this overall growth rate. Things that are not included in the forecast that we're excited to keep working on, efficiencies through innovation. This is everything from how do we continue to improve the efficiency of our machines through things like fast scan or virtual MRI. It is also things like using bots and agentic agents in our call center. Also not included are strategic service lines. This morning, we announced our pilot is going underway around Breast Arterial Calcification, a patient pay add-on in our New Jersey market.
We've seen 12% of patients decide to pay for the increased screening. That's more than we expected. Great feedback. We'll be rolling that out to other markets. Finally, there's no M&A assumed in any of these targets. Any tuck-in acquisitions or larger would be incremental to the stated growth that we put out there. I'm not gonna go through these slides. You can see them online. Transparent updates around our same-site growth, focusing on the MRI and CT. We promised you more visibility to PET. Happy to deliver it. You can see the strong PET growth, 2025. That'll continue to grow in 2026. We've talked about our de novo. Great trajectory last year. Look forward to continuing to build on that.
As these ramp and continue as vintages, and you've got, say, three, they ramp over about four to five years. When you've got three vintages ramping at a time, that'll be a great boost for our same-site growth rate. We've already talked about M&A. It's incredibly fragmented with really strong multiples, opportunities, especially for the smaller sites. With that, I will turn it over to Tony to hit some of our financial numbers.
All right. A three-year trend here, and I think this hits on a lot of information that we'll, you know, kind of routinely present about our volumes, some of it being consolidated, which is the primary metric we have to report, 'cause that's the GAAP, the GAAP metric. The SEC will require that to be prominent. We think it's really useful to see what we call system-wide, which picks up all of our consolidated businesses, but also all that JV business that I was just referring to, 'cause that's almost half the sites we operate are in that JV. If you're gonna understand where our profit's gonna come from, you kinda have to look at the whole pie of revenue. We'll provide that as a supplemental measure, and you'll see both consolidated and system-wide for a lot of metrics.
You can see about in the middle of that, the percent advanced system-wide row. That is showing how volumes that are MRI, CT are growing as a percentage of the work we do year after year. It's 1%-2% a year the last few years. We expect that to continue because of some of the things Caitlin told you about what's driving it in the industry. We also focus on it in terms of how we build out our centers and what capacity they have, and the physician groups that we reach out to and have relationships for referrals. It's very purposeful to grow that line of business. It reimburses at 3 times-4 times higher than more routine modalities like X-ray or ultrasound. That trend is something you'll continue to see.
Also, as we, you know, have gone through the last couple of years, we're seeing the margin expansion you would expect from the unit economics at the site, as well as starting to get a little leverage on the fixed costs at the mothership. Another bit of an eye chart that you might wanna take as a, as a, in the swag bag leaving the conference. The two segments that we operate in, we'll talk most often about the one on the left, which is the outpatient business. This is what you saw the picture of. We take the scan, we do the read, and we get. We bill out one global bill to collect for everything that we do that day.
We turn around and pay a radiologist to interpret the scan based on a contract we have with them. We have to cover the costs of running the site and the four walls. You know, the rent, the equipment there, the technologists, other services that we have to provide. That's where we get our earnings primarily. It's 81% of our business. It's been going up about 1% a year as a proportion of our overall business. When we open new sites, it's all in that c-column. On the right-hand side is a pro fee only business that we do for two of our health system partners. We're happy to do it as part of a broader relationship that we have with them.
We send one of our radiologists to their hospital site solely to read a scan that the hospital has already done. You can see our cost structure is a lot simpler for that. We don't pay really anything to speak of other than paying the radiologist, similar to how we would in one of our centers to interpret the scan. That's growing at a lower rate. It's not our primary business. Lower revenue. The growth metrics are not quite the same there. We'll continue to do it for the two health system partners we do. We're confident they're gonna continue to have a need because there are not enough radiologists wanting to work in the hospital setting by and large.
There will always be a demand by partners we have to want us to help with that, and we will. Most important takeaway of this is you can see the higher growth rate on the outpatient side, 7%-8% versus the pro fee at 4%-5%. That's where our blended top-line revenue growth of 6% comes from. That'll look a little low if you think of us only as a 100% outpatient business. When you look at these two segments together, I think it makes a lot more sense. Won't spend much time here other than to point to the upper right, which is what our leverage ratio has done. You can see even before the IPO, we were delevering while spending plenty of capital to open new de novo this year.
Went down 0.4 times during the first nine months. The IPO took that down another two turns. With the refi of our debt and the pay down, we freed up over $50 million a year of operating cash flow, which will help us take that leverage ratio lower and also continue to fund the growth that we see such great opportunities to carry out. Here's a trend 2024-2026, to just give you an idea of margin. That 7.2% pro forma margin growth you see in 2026 is about what we've had on a CAGR basis over the last three, four, five years. That's kind of a normal level of growth, and it results in some margin expansion.
This is computed on a pro forma basis because in 2026, we, as a newly public company, new as in three weeks before year-end of 2025, we have some new costs to load, you know, for departments we didn't have before, functions we didn't have before that we need. That's gonna create a bit of a bump in our, you know, speed bump in our margin and growth rate for 2026. If you factor that out, our margin is in that range I talked about, the 7%-8% that it's been the last few years. On a reported basis, it'll be more like 4%, because of that $7 million. As for guidance, we issued this earlier. It is right in line.
The midpoint of this is right in line with what I think everybody expected. Again, this has been prepared largely from looking backward at what the business has done for the last three or four years and saying, we're able to keep doing that. There's a lot of upside in this, we think, in terms of opportunities we have to execute beyond it. Caitlin showed you a few of the things we're working on that are, you know, not in the guidance, namely M&A being a big one, which is at least an opportunity for us to undertake, strategically and, you know, surgically. 2026, feel great about this number as we did when we put our model together last fall. It is a seasonal business.
I think if you follow healthcare services companies, you know that the annual deductible reset that hits in January causes Q1 to be noticeably less than Q4, and you kinda build momentum through the year until Q4 is the best quarter of the year. We always have to watch to see how deductible resets affect the business in Q1. There's also weather that can happen this time of year. I understand RadNet mentioned that as well. There have been some bad storms in the country affecting a number of communities, including some where we do business. We feel great about the annual guidance figure.
If we have any sort of differences in terms of timing or spread of how we'll get there, we'll be glad to talk about them when we do our earnings call in a few weeks. Have a little bit more things behind us. Just want to reaffirm we feel like we're on a great trajectory and the guidance we're issuing today is something we feel really good about. Anything else?
Good job.
All right.
Got a couple questions.
Go for it.
We have in our four minutes and 24 seconds left. Glass half empty question. The routine volumes have been a little softer than our model. Is that how we should expect it going forward? Didn't seem to affect your financials, and the advance was better, revenue was in line. Just talk about what's going on with routine imaging volumes.
I appreciate that so much, John. Routine is kind of this catchall bucket for things that are performing well like mammo and ultrasound, and then things like X-ray. X-ray is a large number in terms of the scans and the people we take care of, but the reimbursement, as you said, is much, much lower. We're thinking a lot about what's the right guidance to give you all about how to think about X-ray versus things that matter more, like mammo and ultrasound. Yes, I think you'll see continued softness in X-ray, but it'll have limited to zero impact on overall financials.
One thing, and we did, as you know, a bunch of calls on your IPO, one number we always flag for people is if you look at the revenue per scan in the JVs, it's about $370. If you look at it consolidated, it's about $225. If you look at RadNet, it's about $165. Just help people understand why there would be that big a difference with companies essentially doing the same thing.
Yeah. I think first is what we were just talking about, the acuity mix of advanced versus routine. Within our JVs, we are custom- built to do more routine. We do provide X-ray and ultrasound.
Do more advanced.
Do more advanced.
Do more advanced, excuse me. It's been a long day. Do more advanced. They are custom built around the MRI, the CT, and PET. Whereas our consolidated, tied to more of our physician practices do more of the routine. That obviously has a reimbursement differential that creates more of the mix. Our joint ventures do help us in managed care negotiations. That is certainly part of the strategy as well. When you compare us against RadNet, we have a 63% commercial payer mix. They have in the 50s, and commercial obviously has a higher reimbursement rate than government.
Okay. Just let's forget accounting for a minute, but just capital spending, taking cap lease accounting to the side, which drove me crazy. The, you know, it looks like in our model, you're going from spending about $30 million a year to about $80 million a year for the. I think that's in the plan for the next several years. Talk about the $80 million, kind of what those buckets are and, you know, how should, how we should think about that.
Yeah. Yeah. I think, this is a good example of something we can maybe work to show more transparently in our structure because the difference isn't quite as large as that, just to... as a starting point, but it is a meaningful boost we've made in our spend this year, and we'll continue to next year. The biggest piece of this is, you know, a full third is de novo. You know, we're opening eight to 10 a year. Before 2025, it was three or four a year. That's at $4 million a pop, that's a meaningful boost.
Most of these are JVs, though, right? It'd be half that.
I would say the majority, yeah. I wouldn't say most, but a majority perhaps to,
About the same.
... you know...
Slightly over half.
Yeah. Slightly over half. You know, we are deploying growth capital. When we first open a center, we often leave room to add an MRI later. We'll spend, you know, $1 to one and a $500,000 putting in a new MRI when the demand is there.
Mm
At one of our sites. Smaller pieces on things like the fast scan technology, that cut down the amount of time it takes to do a scan. There's a great ROI on those because you can scan more people in, less time.
All right. I have 45 seconds. My last one would be, it'll be a good day for the stock, I think, when you announce another UPMC type deal. Just talk about the effort in finding JV partners, how much personal time you spend on it, how much time Chris spends on it, and just at any given point in time, how many conversations are happening, what's the funnel, et cetera.
Yeah.
All in 25 seconds.
We love talking to JV partners. It's one of my favorite parts of my job. Brett Brodnax, the former CEO of USPI, obviously has a deep bench as well. We have multiple ongoing conversations right now. I think the parallel to the ASC industry has made it very clear about the value it could create. I mean, beyond Chris, we have Ryan, we have a team, and it's something that we, I personally spend a lot of time on too.
Zero. The clock says zero.
Woo.
See you downstairs.
Thank you.
Thank you for breaking out. Bye.
Thank you.