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COST SUMMARY FORM <br />Total annual cost for inmate medical services. $1,663.732.00 <br />(Including Staffing Cost) <br />Breakdown information: <br />Staffing Cost $1,181,214 <br />Pharmaceutical cost $85,000.00 <br />Supply cost 8625M <br />Other $311.268.00 <br />Additional Services (Section 13.0) <br />Per unit repair cost for Dentures, Plates & Partials $200.00 <br />Per study cost for mobile x -ray service amm <br />(Including Radiologist interpretation, transcription <br />and delivery) <br />Cost per patient visit for Ophthalmology $150.00 <br />Cost per patient visit for OB /G YN $150.00 <br />Cost per visit for Emergency Psychiatric Crisis $50.00 <br />Intervention & Evaluation <br />Monthly administrative fee for billing services $500.00 <br />BIDDERS STATEMENT: I have read, understood and agree to the terms and conditions <br />on all pages of the Request for Proposal. Upon request, I will transfer and deliver goods <br />or services to the City in accordance with said terms and conditions. <br />Correctional Managed Care Medical Corporation (714) 635 -4700 <br />Complete Legal Name of Company Phone Number <br />1475 S. State College Blvd Anaheim, California 92806 <br />Zip Code <br />Director of Finance Niza Guerrero <br />Signature of Authorized Agent — Title Printed Name <br />25J -60 <br />