AMERICAN SHARED HOSPITAL SERVICES 10-K

ITEM 9A. CONTROLS AND PROCEDURES (a) Evaluation of disclosure controls and procedures. Our Chief Executive Officer and our Chief Financial Officer, after evaluating the effectiveness of the Company’s “disclosure controls and procedures” (as defined in the Securities Exchange Act of 1934 (“Exchange Act”) Rules 13a-15(e) and 15d-15(e)) as of the end of the period covered by this annual report, have concluded that our disclosure controls and procedures are effective based on their evaluation of these controls and procedures required by paragraph (b) of Exchange Act Rules 13a-15 or 15d-15. (b) Management’s report on internal control over financial reporting. The management of the Company is responsible for establishing and maintaining adequate internal control over financial reporting. The Company’s internal control system was designed to provide reasonable assurance to its management and Board of Directors regarding the preparation and fair presentation of published financial statements. All internal control systems, no matter how well designed, have inherent limitations. Therefore, even those systems determined to be effective can provide only reasonable assurance with respect to financial statement preparation and presentation. Management assessed the effectiveness of the Company’s internal control over financial reporting as of December 31, 2020. In making this assessment, it used the criteria set forth by the Committee of Sponsoring Organizations of the Treadway Commission in Internal Control – Integrated Framework (2013). Based on this assessment management believes that, as of December 31, 2020, the Company’s internal control over financial reporting is effective based on those criteria. In June 2020, the Company acquired Gamma Knife Center Ecuador S.A. (“GKCE”). Management excluded GKCE from its report on internal controls over financial reporting as of December 31, 2020. GKCE's financial statements constitute 3.8% and 3.6% of the Company’s consolidated total assets (excluding $1,343,000 of goodwill and intangible assets and $19,000 of land, which were integrated into the Company’s control environment), and revenues, respectively. The Company will include GKCE in its assessment of the effectiveness of internal controls over financial reporting in fiscal year 2021 annual management report, the annual management report following the first anniversary of the acquisition. 23 Table of Contents (c) Changes in internal controls over financial reporting. Our Chief Executive Officer and our Chief Financial Officer have evaluated the changes to the Company’s internal control over financial reporting that occurred during our last fiscal quarter ended December 31, 2020, as required by paragraph (d) of Exchange Act Rules 13a-15 and 15d-15, and have concluded that there were no such changes that materially affected, or are reasonably likely to materially affect, the Company’s internal control over financial reporting. ITEM 9B. OTHER INFORMATION None. PART III ITEM 10. DIRECTORS, EXECUTIVE OFFICERS AND CORPORATE GOVERNANCE Information regarding directors is incorporated herein by reference from the Company’s definitive Proxy Statement for the 2021 Annual Meeting of Shareholders (the “2021 Proxy Statement”). Information regarding executive officers of the Company, included herein under the caption “Executive Officers of the Company” in Part I, Item 1 above, is incorporated herein by reference. Information concerning the identification of our standing audit committee required by this Item is incorporated by reference from the 2021 Proxy Statement. Information concerning our audit committee financial experts required by this Item is incorporated by reference from the 2021 Proxy Statement. Information concerning compliance with Section 16(a) of the Exchange Act required by this Item is incorporated by reference from the 2021 Proxy Statement. We have adopted a Code of Ethics that is available on our website at www.ashs.com . The information on our website is not part of this report. You may also request a copy of this document free of charge by writing our Corporate Secretary. ITEM 11. EXECUTIVE COMPENSATION Information required by this Item is incorporated herein by reference from the 2021 Proxy Statement. ITEM 12. SECURITY OWNERSHIP OF CERTAIN BENEFICIAL OWNERS AND MANAGEMENT AND RELATED STOCKHOLDER MATTERS Information required by this Item is incorporated herein by reference from the 2021 Proxy Statement. ITEM 13. CERTAIN RELATIONSHIPS AND RELATED TRANSACTIONS, AND DIRECTOR INDEPENDENCE Information required by this Item is incorporated herein by reference from the 2021 Proxy Statement. ITEM 14. PRINCIPAL ACCOUNTING FEES AND SERVICES Information required by this Item is incorporated herein by reference from the 2021 Proxy Statement. PART IV ITEM 15. EXHIBITS AND FINANCIAL STATEMENT SCHEDULES (a) Financial Statements and Schedules. The following Financial Statements and Schedules are filed with this Report: Report of Independent Registered Public Accounting Firm Audited Consolidated Financial Statements Consolidated Balance Sheets Consolidated Statements of Operations Consolidated Statement of Shareholders' Equity Consolidated Statements of Cash Flows 24 Table of Contents Notes to Consolidated Financial Statements Financial Statement Schedules- no schedules are included since the required information is not present or is not present in amounts sufficient to require submission of the schedule, or because the information required is included in the financial statements and notes thereto. 25 Table of Contents (b) Exhibits. The following Exhibits are filed with this Report. Exhibit Number Incorporated by reference herein Description Form Exhibit Date 3.1 Articles of Incorporation of the Company. 10-Q 001-08789 3.1 5/15/2017 3.1a Certificate of Amendment to Articles of Incorporation of the Company. 10-K 001-08789 3.1 3/27/2017 3.2 By-laws of the Company, as amended and restated dated as of January 27, 2021. 8-K 001-08789 3.1 2/2/2021 4.1 * Description of Securities Registered Pursuant to Section 12 of the Securities Exchange Act of 1934 10-K 001-08789 4.1 4/6/2021 10.1 Operating Agreement for GK Financing, LLC dated as of October 17, 1995 between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. S-1 033-63721 10.12 10/26/1995 10.1a Amendment Agreement dated as of October 26, 1995 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. S-1/A 033-63721 10.13 3/29/1996 10.1b Second Amendment Agreement dated as of December 20, 1995 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. S-1/A 033-63721 10.13 3/29/1996 10.1c Third Amendment Agreement dated as of October 16, 1996 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.13b 3/31/1998 10.1d Amendment Four Agreement dated as of March 31, 1998 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.8 3/31/1999 10.1e Fifth Amendment Agreement dated as of March 31, 1998 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.9 3/31/1999 10.1f Sixth Amendment Agreement dated as of June 5, 1998 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.10 3/31/1999 10.1g Seventh Amendment Agreement dated as of October 18, 2006 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.52 4/2/2007 10.1h Eighth Amendment Agreement dated as of April 28, 2010 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.1h 3/30/2016 10.1i Ninth Amendment Agreement dated as of May 16, 2011 to the GK Financing, LLC Operating Agreement between American Shared Radiosurgery Services, Inc. and GKV Investments, Inc. 10-K 001-08789 10.1i 3/30/2016 26 Table of Contents 10.2 Lease Agreement for a Gamma Knife Unit dated as of October 29, 1996 between GK Financing, LLC and Methodist Healthcare Systems of San Antonio, Ltd., dba Southwest Texas Methodist Hospital. 10-K 001-08789 10.2 3/30/2016 10.2a Addendum to Lease Agreement for a Gamma Knife Unit dated as of October 31, 1996 between GK Financing, LLC and Methodist Healthcare System of San Antonio, Ltd., dba Southwest Texas Methodist Hospital. 10-K 001-08789 10.2a 3/30/2016 10.2b Addendum Two to Lease Agreement for a Gamma Knife Unit dated as of October 16, 1997 between Methodist Healthcare System of San Antonio, Ltd., d.b.a. Southwest Texas Methodist Hospital and GK Financing, LLC. 10-K 001-08789 10.2b 3/30/2016 10.2c Amendment to Lease Agreement for a Gamma Knife Unit dated as of December 13, 2003 between Methodist Healthcare Systems of San Antonio, Ltd., d/b/a Southwest Texas Methodist Hospital and GK Financing, LLC. 10-K 001-08789 10.2c 3/30/2016 10.2d # Second Amendment to Lease Agreement for a Gamma Knife Unit (Perfexion Upgrade) dated as of December 23, 2009 between GK Financing, LLC and Methodist Healthcare Systems of San Antonio, Ltd., d/b/a Southwest Texas Methodist Hospital. 10-Q 001-08789 10.18b 11/15/2010 10.4 Purchased Services Agreement (for a Gamma Knife Unit) dated as of November 19, 2008 between GK Financing, LLC and Kettering Medical Center. 10-Q 001-08789 10.1 8/11/2016 10.4a First Amendment to Purchased Services Agreement (for a Gamma Knife Unit) dated as of June 11, 2009 between GK Financing, LLC and Kettering Medical Center. 10-Q 001-08789 10.1a 8/11/2016 10.4b # Second Amendment to Purchased Services Agreement (for a Gamma Knife Unit) dated as of February 27, 2014 between GK Financing, LLC and Kettering Medical Center. 10-K 001-08789 10.21c 4/1/2015 10.4c # Third Amendment to Purchased Services Agreement (for a Gamma Knife Unit) dated as of March 28, 2019 between GK Financing, LLC and Kettering Medical Center 10-Q 001-08789 10.1 11/7/2019 10.5 # Lease Agreement for a Gamma Knife Unit (Perfexion Upgrade) dated as of July 30, 2013 between Tufts Medical Center, Inc. (FKA New England Medical Center Hospitals, Inc.) and GK Financing, LLC. 10-K 001-08789 10.22b 3/31/2014 10.5a # First Amendment to Lease Agreement for a Gamma Knife Unit (Perfexion Upgrade) dated as of April 23, 2020 between Tufts Medical Center, Inc. (FKA New England Medical Center Hospitals, Inc.) and GK Financing, LLC. 10-Q 001-08789 10.1 8/14/2020 10.6 # Amended and Restated Equipment Lease Agreement (for a Gamma Knife Unit) dated as of December 12, 2014, between GK Financing, LLC and the Board of Trustees of the University of Arkansas on behalf of the University of Arkansas for Medical Sciences. 10-Q 001-08789 10.4 8/19/2015 10.10 Lease Agreement for a Gamma Knife Unit dated as of November 1, 1999 between GK Financing, LLC and Jackson HMA, Inc. d/b/a Central Mississippi Medical Center. 10-K 001-08789 10.10 3/30/2016 10.10a Addendum to Lease Agreement for a Gamma Knife Unit dated as of November 1, 1999 between Jackson HMA, Inc. dba Central Mississippi Medical Center and GK Financing, LLC. 10-Q 001-08789 10.34 8/10/2001 10.10b # Addendum Two to Lease Agreement for a Gamma Knife Unit dated as of November 6, 2006 between GK Financing, LLC and Jackson HMA, Inc. d/b/a Central Mississippi Medical Center. 10-K 001-08789 10.51 4/2/2007 27 Table of Contents 10.10c Amendment Three to Lease Agreement for a Gamma Knife Unit dated as of February 23, 2010 between GK Financing, LLC and Jackson HMA, LLC d/b/a Central Mississippi Medical Center. 10-K 001-08789 10.10c 3/30/2016 10.10d Amendment Four to Lease Agreement for a Gamma Knife Unit dated as of May 1, 2019 between GK Financing, LLC and Jackson HMA, LLC d/b/a Central Mississippi Medical Center. 10-Q 001-08789 10.1 5/11/2020 10.11 Lease Agreement for a Gamma Knife Unit dated as of February 18, 2000 between GK Financing, LLC and OSF HealthCare System. 10-K 001-08789 10.11 3/30/2016 10.11a Addendum to Lease Agreement for a Gamma Knife Unit dated as of April 13, 2007, between GK Financing, LLC and OSF Healthcare System. 10-Q 001-08789 10.2 8/11/2016 10.11b Addendum Two to Lease Agreement for a Gamma Knife Unit dated as of October 31, 2012 between GK Financing, LLC and OSF Healthcare System. 10-Q 001-08789 10.2a 8/11/2016 10.11c # Addendum Three to Lease Agreement for a Gamma Knife Unit dated as of June 7, 2016 between GK Financing, LLC and OSF Healthcare System. 10-Q 001-08789 10.2b 8/11/2016 10.11d * Addendum Four to Lease Agreement for a Gamma Knife Unit dated as of February 6, 2020 between GK Financing, LLC and OSF Healthcare System. 10-K 001-08789 10.11d 4/6/2021 10.13 Equipment Lease Agreement (for a Gamma Knife Unit) dated as of February 13, 2003 between GK Financing, LLC and AHS Albuquerque Regional Medical Center, LLC. 10-K 001-08789 10.13 3/30/2016 10.13a # Amendment to Equipment Lease Agreement (Perfexion Upgrade) dated as of April 8, 2011 between GK Financing, LLC and Lovelace Health System, Inc., d/b/a Lovelace Medical Center. 10-Q 001-08789 10.62 8/15/2011 10.13b Assignment and Assumption of Purchase and License Agreement dated as of February 2, 2011 between Elekta, Inc., GK Financing, LLC and Albuquerque GK Equipment, LLC. 10-Q 001-08789 10.62a 8/15/2011 10.13c # Icon Upgrade and Amendment Two to Equipment Lease Agreement for a Gamma Knife Unit dated as of October 15, 2019 between GK Financing, LLC and Lovelace Health System, Inc., d/b/a Lovelace Medical Center. 10-Q 001-08789 10.1 11/13/2020 10.14 Equipment Lease Agreement (for a Gamma Knife Unit) dated as of March 21, 2003 between GK Financing, LLC and Northern Westchester Hospital Center. 10-K 001-08789 10.14 3/30/2016 10.14a # Amendment to Equipment Lease Agreement (Perfexion Upgrade) dated as of June 8, 2012 between GK Financing, LLC and Northern Westchester Hospital Center. 10-Q 001-08789 10.46a 8/14/2013 10.16 # Purchased Services Agreement (for a Gamma Knife Unit) dated as of March 5, 2008 between GK Financing, LLC and USC University Hospital, Inc. 10-Q 001-08789 10.57 5/14/2008 10.16a # First Amendment to Purchased Services Agreement (for a Gamma Knife Unit) dated as of April 1, 2009 between GK Financing, LLC and University of Southern California. 10-Q 001-08789 10.57a 8/14/2009 10.16b # Second Amendment to Purchased Services Agreement (for a Gamma Knife Unit) dated as of October 1, 2013 between GK Financing, LLC and University of Southern California. 10-Q 001-08789 10.57b 8/14/2014 28 Table of Contents 10.16c Third Amendment to Purchased Services Agreement dated as June 30, 2020 between GK Financing, LLC and University of Southern California. 10-Q 001-08789 10.2 11/13/2020 10.17 # Equipment Lease Agreement (for a Gamma Knife Unit) dated as of May 1, 2010 between GK Financing, LLC and Fort Sanders Regional Medical Center. 10-Q 001-08789 10.60 5/16/2011 10.17a Amendment to Lease Agreement (for a Gamma Knife Unit) dated as of January 3, 2012 between GK Financing, LLC and Fort Sanders Regional Medical Center. 10-K 001-08789 10.17a 3/30/2016 10.17b Second Amendment to Equipment Lease Agreement (for a Gamma Knife Unit) dated as of June 1, 2017 between GK Financing, LLC and Fort Sanders Regional Medical Center 10-Q 001-08789 10.2 8/10/2017 10.18 # Leksell Gamma Knife Perfexion Purchased Services Agreement dated as of August 5, 2011 between Jacksonville GK Equipment, LLC and St. Vincent’s Medical Center, Inc. 10-K 001-08789 10.63 3/30/2012 10.18a # First Amendment to the Leksell Gamma Knife Perfexion Purchased Services Agreement dated as of October 10, 2011 between Jacksonville GK Equipment, LLC and St. Vincent’s Medical Center, Inc. 10-K 001-08789 10.63a 3/30/2012 10.19 # Leksell Gamma Knife Perfexion Purchased Services Agreement dated as of January 19, 2012 between GK Financing, LLC and Sacred Heart Health System, Inc. 10-Q 001-08789 10.65 5/15/2013 10.20 # Leksell Gamma Knife Perfexion Purchased Services Agreement dated as of March 27, 2014 between GK Financing, LLC and PeaceHealth doing business through its operating division PeaceHealth Sacred Heart Medical Center at RiverBend. 10-K 001-08789 10.67 4/1/2015 10.21 # Equipment Lease Agreement (for a Gamma Knife Unit) dated as of February 21, 2017 between Bryan Medical Center, and GK Financing, LLC. 10-Q 001-08789 10.1 11/13/2017 10.21a # First Amendment to Equipment Lease Agreement (for a Gamma Knife unit) dated as of February 14, 2018 between Bryan Medical Center and GK Financing, LLC 10-Q 001-08789 10.1 5/10/2018 10.22 # Proton Beam Radiation Therapy Lease Agreement dated as of October 18, 2006 between American Shared Hospital Services and Orlando Regional Healthcare System, Inc. 10-Q 001-08789 10.3 8/11/2016 10.22a # Amendment One to Proton Beam Radiation Therapy Lease Agreement dated as of August 12, 2012 between American Shared Hospital Services and Orlando Health, Inc., formerly known as Orlando Regional Healthcare System, Inc. 10-Q 001-08789 10.3a 8/11/2016 10.23 # Equipment Lease Agreement (for a Gamma Knife Unit) dated as of May 8, 2018 between The Methodist Hospitals, Inc. and GK Financing, LLC 10-Q 001-08789 10.1 5/13/2019 10.24 • American Shared Hospital Services Incentive Compensation Plan as Amended and Restated effective June 21, 2019 10-Q 001-08789 10.1 8/13/2019 10.25 • Form of Indemnification Agreement between American Shared Hospital Services and members of its Board of Directors. 10-K 001-08789 10.26 3/30/2016 10.26 • Form of American Shared Hospital Services Incentive Compensation Plan Performance Share Award Agreement. 10-K 001-08789 10.25 3/27/2017 10.27 • Offer Letter between the Company and Mr. Raymond C. Stachowiak dated April 22, 2020 8-K 001-08789 10.27 4/22/2020 21.1 * Subsidiaries of American Shared Hospital Services 23.1 * Consent of Independent Registered Public Accounting Firm 29 Table of Contents 31.1 * Certification of Chief Executive Officer pursuant to Rule 13a-14a/15d-14a, as adopted pursuant to Section 302 of the Sarbanes-Oxley Act of 2002 31.2 * Certification of Chief Financial Officer pursuant to Rule 13a-14a/15d-14a, as adopted pursuant to Section 302 of the Sarbanes-Oxley Act of 2002 32.1 ǂ Certifications of Chief Executive Officer and Chief Financial Officer pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002 101.INS * XBRL Instance Document 101.SCH * XBRL Taxonomy Extension Schema Document 101.CAL * XBRL Taxonomy Calculation Linkbase Document 101.DEF * XBRL Taxonomy Definition Linkbase Document 101.LAB * XBRL Taxonomy Label Linkbase Document 101.PRE * XBRL Taxonomy Extension Presentation Linkbase Document 104 * Cover Page Interactive Data File – the cover page XBRL tags are embedded within the Inline Instance XBRL Document * Filed herewith. ǂ Furnished herewith. # Confidential material appearing in this document has been omitted and filed separately with the Securities and Exchange Commission in accordance with Rule 24b-2, promulgated under the Securities and Exchange Act of 1934, as amended. Omitted information has been replaced with asterisks. • Indicates management compensatory plan, contract, or arrangement. ITEM 16. FORM 10-K SUMMARY The Optional summary in Item 16 has not been included in this Form 10-K. 30 Table of Contents SIGNATURES Pursuant to the requirements of Section 13 or 15(d) of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned, thereunto duly authorized. AMERICAN SHARED HOSPITAL SERVICES (Registrant) April 6, 2021 By: /s/ Raymond C. Stachowiak Raymond C. Stachowiak Chief Executive Officer Pursuant to the requirements of the Securities Exchange Act of 1934, this report has been signed below by the following persons on behalf of the registrant in the capacities and on the dates indicated. Signature Title Date /s/ Raymond C. Stachowiak Chief Executive Officer April 6, 2021 Raymond C. Stachowiak /s/ Ernest A. Bates Chairman of the Board April 6, 2021 Ernest A. Bates, M.D. /s/ Daniel G. Kelly Jr. Director April 6, 2021 Daniel G. Kelly JR. /s/ David A. Larson Director April 6, 2021 David A. Larson, M.D. /s/ Sandra A. J. Lawrence Director April 6, 2021 Sandra A. J. Lawrence /s/ S. Mert Ozyurek Director April 6, 2021 S. Mert Ozyurek /s/ Craig K. Tagawa President, Chief Operating Officer and Chief Financial Officer (Principal Accounting Officer) April 6, 2021 Craig K. Tagawa 31 Table of Contents AMERICAN SHARED HOSPITAL SERVICES REPORT OF INDEPENDENT REGISTERED PUBLIC ACCOUNTING FIRM and CONSOLIDATED FINANCIAL STATEMENTS AS OF December 31, 2020 and 2019, and FOR THE YEARS ENDED DECEMBER 31, 2020 CONTENTS PAGE REPORT OF INDEPENDENT REGISTERED PUBLIC ACCOUNTING FIRM F- 3 C ONSOLIDATED F INANCIAL S TATEMENTS Balance sheets F- 6 Statements of operations F- 7 Statement of shareholders’ equity F- 8 Statements of cash flows F- 9 Notes to financial statements F- 11 32 Table of Contents Report of Independent Registered Public Accounting Firm To the Shareholders and the Board of Directors of American Shared Hospital Services, Inc. Opinion on the Financial Statements We have audited the accompanying consolidated balance sheets of American Shared Hospital Services, Inc. (the “Company”) as of December 31, 2020 and 2019, and the related consolidated statements of operations, shareholders’ equity and cash flows for the years then ended, and the related notes. In our opinion, the consolidated financial statements present fairly, in all material respects, the consolidated financial position of the Company as of December 31, 2020 and 2019, and the consolidated results of its operations and its cash flows for the years then ended, in conformity with accounting principles generally accepted in the United States of America. Basis for Opinion These consolidated financial statements are the responsibility of the Company’s management. Our responsibility is to express an opinion on the Company’s consolidated financial statements based on our audits. We are a public accounting firm registered with the Public Company Accounting Oversight Board (United States) (“PCAOB”) and are required to be independent with respect to the Company in accordance with the U.S. federal securities laws and the applicable rules and regulations of the Securities and Exchange Commission and the PCAOB. We conducted our audits in accordance with the standards of the PCAOB. Those standards require that we plan and perform the audits to obtain reasonable assurance about whether the consolidated financial statements are free of material misstatement, whether due to error or fraud. The Company is not required to have, nor were we engaged to perform, an audit of its internal control over financial reporting. As part of our audits we are required to obtain an understanding of internal control over financial reporting but not for the purpose of expressing an opinion on the effectiveness of the Company’s internal control over financial reporting. Accordingly, we express no such opinion. Our audits included performing procedures to assess the risks of material misstatement of the consolidated financial statements, whether due to error or fraud, and performing procedures to respond to those risks. Such procedures included examining, on a test basis, evidence regarding the amounts and disclosures in the consolidated financial statements. Our audits also included evaluating the accounting principles used and significant estimates made by management, as well as evaluating the overall presentation of the consolidated financial statements. We believe that our audits provide a reasonable basis for our opinion. Critical Audit Matters The critical audit matters communicated below are matters arising from the current period audit of the consolidated financial statements that was communicated or required to be communicated to the audit committee and that (1) relates to accounts or disclosures that are material to the consolidated financial statements and (2) involved our especially challenging, subjective, or complex judgments. The communication of critical audit matters does not alter in any way our opinion on the consolidated financial statements, taken as a whole, and we are not, by communicating the critical audit matter below, providing a separate opinion on the critical audit matter or on the accounts or disclosures to which they relate. Retail Revenue Recognition – Estimates of Reimbursement Rates and Payor Mix As discussed in Note 2 in the Company’s consolidated financial statements, retail revenue amounted to approximately $11,418,000, which was approximately 64% of total consolidated revenue, during the year ended December 31, 2020. The related accounts receivable balance for total retail sites accounted for 68% of total accounts receivable at December 31, 2020. The Company has retail customer revenue classified as either turn-key or revenue sharing that are recognized under Accounting Standards Codification (“ASC”) 842 Leases (“ASC 842”). Under revenue sharing arrangements, the Company receives a contracted percentage of the reimbursement received by the hospital. Under turn-key arrangements, the Company receives payment from the hospital based on the amount of the hospital’s reimbursement from third party payors. We identified management’s estimates of reimbursement rates and payor mix to record retail revenue and related accounts receivable, as a critical audit matter. Retail revenue and related accounts receivable involves significant judgment and estimation, including measurement uncertainty, by management based on the estimates and assumptions used and are subject to adjustments based on actual reimbursements received by the Company. In turn, auditing management’s judgments and estimates related to retail revenue and related accounts receivable involved a high degree of subjectivity, as they are based on estimates of reimbursement rates and payor mix. The primary procedures we performed to address this critical audit matter included: a. Obtaining management’s reconciliation of retail revenue and accounts receivable by site agreeing to supporting documentation related to the estimated reimbursement rates and payor mix used in the calculation. F- 3 Table of Contents a. Obtaining third party confirmations, confirming number of procedures, payment dates and amounts paid, and reconciling confirmed amounts to management’s reconciliation, in order to validate approximate rate per procedure. a. Testing subsequent cash receipts and evaluating the reasonableness of the estimates through a look-back analysis over retail revenue as compared to accounts receivable balances previously recognized. a. Developing an independent expectation of reimbursement rates per procedure based on historical trends, procedures, and payment amounts received through confirmation directly with the hospital, and comparing to management’s estimates. Property and Equipment - Salvage Value on Equipment As described in Note 2 to the consolidated financial statements, property and equipment are stated at cost less accumulated depreciation. Depreciation for Gamma Knife, and other equipment is determined using the straight-line method over the estimated useful lives of the assets, which for medical and office equipment is generally 3 – 10 years, and after accounting for salvage value on the equipment where indicated. Salvage value is based on the estimated fair value of the equipment at the end of its useful life. We identified management’s estimates of salvage value including qualitative assessments of certain equipment as a critical audit matter. Determination of salvage values involves significant judgment and estimation, involving measurement uncertainty, as there is no active resale market for the Gamma Knife units due to limited sellers and buyers and trade-ins for the equipment are not guaranteed. Trade-ins are highly dependent on future demand, values and the Company’s relationship with supplier, a related party of the Company. In turn, auditing management’s judgments and estimates related to salvage value of certain equipment, involved a high degree of subjectivity. The primary procedure we performed to address this critical audit matter included: a. Evaluating management’s determination of salvage values by comparing determined salvages values with historical trade-in transactions and publicly available transaction information, which included reviewing relevant purchase agreements, supplier agreements and evaluating publicly available transaction information. Valuation of Certain Tangible and Intangible Assets Acquired Through Business Combination As described in Note 4 to the consolidated financial statements, the Company completed the acquisition of Gamma Knife Center Ecuador S.A. (“GKCE”) from GKCE’s selling majority shareholders in June 2020. The Company subsequently executed agreements to acquire 1.3% of the total outstanding shares in July 2020 and intends to acquire the remaining 0.7% at later date. The total purchase consideration for 100% of the outstanding shares of GKCE was approximately $2,869,000, including a base purchase price of $2,000,000, subject to certain price adjustments for current assets and liabilities and tax withholding. The transaction was accounted for as a business combination using the acquisition method, whereby the total consideration transferred, identifiable assets acquired, and liabilities assumed are based on the respective acquisition-date fair values. As part of the acquisition, the Company acquired tangible assets, including building, equipment and other property and equipment with a fair value of approximately $723,000 and intangible assets, consisting of the acquired entity’s trade name, with a fair value of approximately $78,000. We identified the judgment and estimation of the methodologies and assumptions used in the valuation by management, in the determination of the fair value of these assets, as a critical audit matter. Significant assumptions used to estimate the fair value of these tangible and intangible assets included discount rates, useful lives, expected future cash flows, internal rate of return, revenue forecast and growth rates. Given these factors, the related audit effort in evaluating management’s estimates required a high degree of auditor judgment. The primary procedures we performed to address this critical audit matter included: a. Evaluating the appropriateness of the methodologies and assumptions used to estimate the fair value of certain tangible (real property and equipment) and intangible (trade name) assets, including involving valuation specialists, where specialized skill or knowledge was needed, to assist with our evaluation. Our valuation specialist assisted primarily in the evaluation of the qualification of the appraiser and valuation specialist used by management, consideration of methodologies used in the appraisal of real property, including review of market information utilized to determine fair value, and in relation to the valuation of trade name, review of the methodology, discount rate, royalty rate, useful life (indefinite), and internal rate of return. F- 4 Table of Contents a. Evaluating assumptions and inputs used in projected financial information of the acquired entity, which primarily related to revenue growth rates, including testing the completeness and accuracy of the underlying data supporting the significant assumptions and estimates. Specifically, when evaluating the assumptions related to the revenue growth rates and changes in the business that would drive these forecasted growth rates, we compared the assumptions to industry trends and subsequent interim period results to evaluate management’s estimates as of the date of the transaction. /s/ Moss Adams LLP San Francisco, California April 6, 2021 We have served as the Company’s auditor since 2000. F- 5 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES C ONSOLIDATED B ALANCE S HEETS DECEMBER 31, 2020 2019 ASSETS CURRENT ASSETS Cash and cash equivalents $ 3,961,000 $ 1,429,000 Restricted cash 364,000 350,000 Accounts receivable, net of allowance for doubtful accounts of $ 100,000 at December 31, 2020 and December 31, 2019 4,303,000 6,894,000 Other receivables 272,000 169,000 Prepaid expenses and other current assets 1,950,000 1,900,000 Total current assets 10,850,000 10,742,000 PROPERTY AND EQUIPMENT, net 30,418,000 41,480,000 LAND 19,000 — GOODWILL 1,265,000 — INTANGIBLE ASSETS 78,000 — RIGHT OF USE ASSETS 886,000 1,106,000 OTHER ASSETS 137,000 455,000 TOTAL ASSETS $ 43,653,000 $ 53,783,000 LIABILITIES AND SHAREHOLDERS’ EQUITY CURRENT LIABILITIES Accounts payable $ 683,000 $ 557,000 Employee compensation and benefits 405,000 234,000 Other accrued liabilities 2,045,000 1,779,000 Asset retirement obligations 1,270,000 — Income taxes payable 373,000 130,000 Working capital payment due 197,000 — Current portion of lease liabilities 305,000 279,000 Current portion of long-term debt 1,157,000 1,526,000 Current portion of finance leases 5,945,000 3,709,000 Total current liabilities 12,380,000 8,214,000 LONG-TERM LEASE LIABILITIES, less current portion 581,000 827,000 LONG-TERM DEBT, less current portion 3,440,000 1,954,000 LONG-TERM FINANCE LEASES, less current portion 2,974,000 8,177,000 DEFERRED REVENUE, less current portion 210,000 286,000 DEFERRED INCOME TAXES 418,000 2,514,000 COMMITMENTS AND CONTINGENCIES (See Note 12) SHAREHOLDERS’ EQUITY Common stock, no par value Common stock, no par value ( 10,000,000 authorized; Issued and outstanding shares – 5,791,000 at December 31, 2020 and 5,817,000 at December 31, 2019 10,753,000 10,753,000 Additional paid-in capital 7,024,000 6,725,000 Retained earnings 1,497,000 8,555,000 Total equity- American Shared Hospital Services 19,274,000 26,033,000 Non-controlling interests in subsidiaries 4,376,000 5,778,000 Total shareholders’ equity 23,650,000 31,811,000 TOTAL LIABILITIES AND SHAREHOLDERS’ EQUITY $ 43,653,000 $ 53,783,000 S ee accompanying notes F- 6 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES CONSOLIDATED S TATEMENTS O F O PERATIONS YEARS ENDED DECEMBER 31, 2020 2019 Revenues $ 17,837,000 $ 20,605,000 17,837,000 20,605,000 Costs of revenue: Maintenance and supplies 2,385,000 2,618,000 Depreciation and amortization 6,789,000 7,341,000 Other direct operating costs 4,197,000 3,726,000 13,371,000 13,685,000 Gross margin 4,466,000 6,920,000 Selling and administrative expense 4,608,000 4,060,000 Interest expense 1,057,000 1,318,000 Loss on write down of impaired assets and associated removal costs 8,264,000 — Operating (loss) income ( 9,463,000 ) 1,542,000 Interest and other income 10,000 16,000 (Loss) income before income taxes ( 9,453,000 ) 1,558,000 Income tax (benefit) expense ( 1,737,000 ) 128,000 Net (loss) income ( 7,716,000 ) 1,430,000 Less: net loss (income) attributable to non-controlling interests 658,000 ( 771,000 ) Net (loss) income attributable to American Shared Hospital Services $ ( 7,058,000 ) $ 659,000 Net (loss) income per share attributable to American Shared Hospital Services: (Loss) income per common share- basic $ ( 1.14 ) $ 0.11 (Loss) income per common share- diluted $ ( 1.14 ) $ 0.11 S ee accompanying notes F- 7 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES C ONSOLIDATED S TATEMENT O F S HAREHOLDERS ’ E QUITY YEARS ENDED DECEMBER 31, 2020 AND 2019 Common Shares Common Stock Additional Paid-in Capital Retained Earnings Sub-Total ASHS Non-controlling Interests in Subsidiaries Total Balances at December 31, 2018 5,714,000 $ 10,711,000 $ 6,495,000 $ 7,896,000 $ 25,102,000 $ 5,946,000 $ 31,048,000 Stock-based compensation expense 4,000 — 230,000 — 230,000 — 230,000 Options exercised 16,000 42,000 — — 42,000 — 42,000 Issuance of restricted stock awards 83,000 — — — — — — Cash distributions to non-controlling interests — — — — — ( 939,000 ) ( 939,000 ) Net income — — — 659,000 659,000 771,000 1,430,000 Balances at December 31, 2019 5,817,000 $ 10,753,000 $ 6,725,000 $ 8,555,000 $ 26,033,000 $ 5,778,000 $ 31,811,000 Stock-based compensation expense 103,000 — 299,000 — 299,000 — 299,000 Cash distributions to non-controlling interests — — — — — ( 761,000 ) ( 761,000 ) NCI investment in acquisition — — — — — 17,000 17,000 Restricted common shares returned to plan ( 129,000 ) — — — — — — Net (loss) income — — — ( 7,058,000 ) ( 7,058,000 ) ( 658,000 ) ( 7,716,000 ) Balances at December 31, 2020 5,791,000 $ 10,753,000 $ 7,024,000 $ 1,497,000 $ 19,274,000 $ 4,376,000 $ 23,650,000 S ee accompanying notes F- 8 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES C ONSOLIDATED S TATEMENTS O F C ASH F LOWS YEARS ENDED DECEMBER 31, 2020 2019 OPERATING ACTIVITIES Net (loss) income $ ( 7,716,000 ) $ 1,430,000 Adjustments to reconcile net income to net cash from operating activities (excluding assets acquired and liabilities assumed): Depreciation and amortization 6,970,000 7,411,000 Non cash lease expense 288,000 256,000 Loss on write down impaired assets 8,184,000 — Deferred income taxes ( 2,162,000 ) ( 444,000 ) Accrued interest on lease financing — 29,000 Stock-based compensation expense 299,000 230,000 Interest expense associated with lease liabilities 65,000 76,000 Changes in operating assets and liabilities: Receivables 2,966,000 ( 1,187,000 ) Prepaid expenses and other assets 762,000 260,000 Accounts payable, accrued liabilities and deferred revenue 263,000 28,000 Lease liabilities ( 353,000 ) ( 332,000 ) Income taxes payable 179,000 130,000 Net insurance proceeds receivable — 160,000 Net cash from operating activities 9,745,000 8,047,000 INVESTING ACTIVITIES Payment for purchase of property and equipment ( 455,000 ) ( 990,000 ) Payment for acquisition, net of cash acquired ( 2,084,000 ) — Proceeds from sale of equipment 150,000 — Net cash (used in) investing activities ( 2,389,000 ) ( 990,000 ) FINANCING ACTIVITIES Principal payments on long-term debt ( 1,726,000 ) ( 1,980,000 ) Principal payments on finance leases ( 3,199,000 ) ( 4,142,000 ) Proceeds from financing from acquisition 1,425,000 — Distributions to non-controlling interests ( 761,000 ) ( 939,000 ) Debt issuance costs ( 30,000 ) — Proceeds from warrants and options exercised — 42,000 Principal payments on short-term financing ( 519,000 ) ( 51,000 ) Net cash (used in) financing activities ( 4,810,000 ) ( 7,070,000 ) Net change in cash, cash equivalents and restricted cash 2,546,000 ( 13,000 ) CASH, CASH EQUIVALENTS AND RESTRICTED CASH, beginning of year 1,779,000 1,792,000 CASH, CASH EQUIVALENTS AND RESTRICTED CASH, end of year $ 4,325,000 $ 1,779,000 F- 9 Table of Contents SUPPLEMENTAL CASH FLOW DISCLOSURE Cash paid for interest $ 938,000 $ 1,318,000 Cash paid for income taxes $ 339,000 $ 397,000 SCHEDULE OF NONCASH INVESTING AND FINANCING ACTIVITIES Lease reassessment right of use assets and lease liabilities $ 67,000 $ — Right of use assets and lease liabilities $ 135,000 $ 1,362,000 Interest capitalized to property and equipment $ 119,000 $ 110,000 Acquisition of equipment with finance leases $ 496,000 $ 1,293,000 Acquisition of equipment with long-term debt financing $ 1,184,000 $ — Acquisition of insurance with short-term financing $ 634,000 $ 526,000 First working capital payment related to acquisition, withholding taxes $ 43,000 $ — Estimated subsequent working capital payment for acquisition $ 154,000 $ — S ee accompanying notes F- 10 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 1 – B USINESS AND B ASIS OF P RESENTATION Business – These consolidated financial statements include the accounts of American Shared Hospital Services and its subsidiaries (the “Company”) as follows: the Company wholly-owns the subsidiaries American Shared Radiosurgery Services (“ASRS”), PBRT Orlando, LLC (“Orlando”), OR21, Inc., and MedLeader.com, Inc. (“MedLeader”); the Company is the majority owner of Long Beach Equipment, LLC (“LBE”); ASRS is the majority-owner of GK Financing, LLC (“GKF”) which wholly-owns the subsidiary Instituto de Gamma Knife del Pacifico S.A.C. (“GKPeru”). GKF is the majority owner of the subsidiaries Albuquerque GK Equipment, LLC (“AGKE”) and Jacksonville GK Equipment, LLC (“JGKE”). GKF formed HoldCo GKC S.A. (“HoldCo”) to acquire Gamma Knife Center Ecuador S.A. (“GKCE”). The Company (through ASRS) and Elekta AG (“Elekta”), the manufacturer of the Gamma Knife (through its wholly-owned United States subsidiary, GKV Investments, Inc.), entered into an operating agreement and formed GKF. During 2020 GKF provided Gamma Knife units to fifteen medical centers in the United States in the states of Arkansas, California, Florida, Illinois, Indiana, Massachusetts, Mississippi, Nebraska, New Mexico, New York, Ohio, Oregon, Tennessee, and Texas. GKF also owns and operates single-unit Gamma Knife facilities in Lima, Peru and Guayaquil, Ecuador. The Company through its wholly-owned subsidiary, Orlando, provided proton beam radiation therapy (“PBRT”) and related equipment to a customer in the United States. The Company formed the subsidiary GKPeru and acquired GKCE for the purposes of expanding its business internationally; Orlando and LBE to provide PBRT equipment and services in Orlando, Florida and Long Beach, California, respectively; and AGKE and JGKE to provide Gamma Knife equipment and services in Albuquerque, New Mexico and Jacksonville, Florida, respectively. AGKE began operations in the second quarter of 2011 and JGKE began operations in the fourth quarter of 2011. Orlando treated its first patient in April 2016. GKPeru treated its first patient in July 2017. LBE is not expected to generate revenue within the next two years. On June 12, 2020, GKF, through HoldCo, purchased approximately 98 % of the total outstanding shares of GKCE, from GKCE’s majority shareholders (the “Acquisition”). As of December 31, 2020, the Company had acquired approximately 99.3 % of the total outstanding shares of GKCE and intends to acquire the remaining 0.7 % at a later date. The base purchase price for the Acquisition, including acquisition of the minority shares was approximately $ 2,000,000 . This purchase price was paid with $ 575,000 in cash and a $ 1,425,000 loan from the United States International Development Finance Corporation (“DFC”). The purchase price is subject to certain post-closing adjustments, including adjustment for GKCE's working capital and excess cash. The DFC loan is denominated in U.S. dollars, which is also the currency of Ecuador. See “Note 4. GKCE Acquisition” for further discussion. The Company continues to develop its design and business model for The Operating Room for the 21st Century SM through its 50 % owned OR21, LLC (“OR21”). The remaining 50 % of OR21 is owned by an architectural design company. OR21 is not expected to generate significant revenue within the next two years. MedLeader was formed to provide continuing medical education online and through videos for doctors, nurses, and other healthcare workers. This subsidiary is not operational at this time. All significant intercompany accounts and transactions have been eliminated in consolidation. The Company is subject to risks and uncertainties as a result of the COVID-19 pandemic and the extent and duration of the future impact on the Company's business is highly uncertain and difficult to predict. The COVID-19 pandemic has adversely impacted, and is likely to further adversely impact, nearly all aspects of the Company’s business and markets, including its employees, operations, contractors, customers, government and third party payors and others. The full extent to which the pandemic will directly or indirectly impact the Company's business, results of operations and financial condition will depend on future developments that are highly uncertain and difficult to predict. F- 11 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 2 – A CCOUNTING P OLICIES Use of estimates in the preparation of financial statements – In preparing the consolidated financial statements in conformity with accounting principles generally accepted in the United States of America, management makes estimates and assumptions that affect the reported amounts of assets and liabilities and disclosures of contingent assets and liabilities at the date of the consolidated financial statements, as well as the reported amounts of revenues and expenses during the reporting period. Significant accounting estimates reflected in the Company’s consolidated financial statements include the estimated useful lives of fixed assets and its salvage values, revenues and costs of sales for turn-key and revenue sharing arrangements. Actual results could differ from those estimates. Advertising costs – The Company expenses advertising costs as incurred. Advertising costs were $ 237,000 and $ 144,000 during the years ended December 31, 2020 and 2019. Advertising costs are recorded in other direct operating costs and sales and administrative costs in the consolidated statements of operations. Cash and cash equivalents – The Company considers all liquid investments with original maturities of three months or less at the date of purchase to be cash equivalents. Restricted cash is not considered a cash equivalent for purposes of the consolidated statements of cash flows. Restricted cash – Restricted cash represents the minimum cash that must be maintained in GKF to fund operations, per the subsidiary’s operating agreement, the minimum cash that must be maintained by GKF per it’s financing agreement with DFC, and the minimum cash that must be maintained in Orlando per the subsidiary’s financing agreement. Business and credit risk – The Company maintains its cash balances, which exceed federally insured limits, in financial institutions. The Company believes it is not exposed to any significant credit risk on cash, cash equivalents. The Company monitors the financial condition of the financial institutions it uses on a regular basis. All of the Company’s revenue was provided by eighteen and seventeen customers in 2020 and 2019. One customer accounted for approximately 35 % and 30 % of the Company’s total revenue in 2020 and 2019. At December 31, 2020, four customers each individually accounted for 11 %, 11 %, 11 % and 20 % of total accounts receivable, respectively. At December 31, 2019, three customers each individually accounted for 12 %, 15 % and 30 % of total accounts receivable, respectively. The Company performs credit evaluations of its customers and generally does not require collateral. The Company has not experienced significant losses related to receivables from individual customers or groups of customers in any particular geographic area. All of the Company’s radiosurgery devices have been purchased through Elekta, to date. However, there are other manufacturers that also make radiosurgery devices. Accounts receivable and doubtful accounts – Accounts receivable are recorded at net realizable value. An allowance for doubtful accounts is estimated based on historical collections plus an allowance for probable losses. Receivables are considered past due based on contractual terms and are charged off in the period that they are deemed uncollectible. Recoveries of receivables previously charged off are offset against bad debt expense when received. Non-controlling interests - The Company reports its non-controlling interests as a separate component of shareholders’ equity. The Company also presents the consolidated net income and the portion of the consolidated net income allocable to the non-controlling interests and to the shareholders of the Company separately in its consolidated statements of operations. Property and equipment – Property and equipment are stated at cost less accumulated depreciation. Depreciation for Gamma Knife, IGRT, and other equipment is determined using the straight-line method over the estimated useful lives of the assets, which for medical and office equipment is generally 3 – 10 years, and after accounting for salvage value on the equipment where indicated. Salvage value is based on the estimated fair value of the equipment at the end of its useful life. The Company acquired a building as part of the Acquisition in June 2020. Depreciation for buildings is determined using the straight-line method over 20 years. F- 12 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 2 – A CCOUNTING P OLICIES (CONTINUED) Depreciation for PBRT and related equipment is determined using the modified units of production method, which is a function of both time and usage of the equipment. This depreciation method allocates costs considering the projected volume of usage through the useful life of the PBRT unit, which has been estimated at 20 years. The estimated useful life of the PBRT unit is consistent with the estimated economic life of 20 years. The Company capitalizes interest incurred on property and equipment that is under construction, for which deposits or progress payments have been made. When a rate is not readily available, imputed interest is calculated using the Company’s incremental borrowing rate. The interest capitalized for property and equipment is the portion of interest cost incurred during the acquisition periods that could have been avoided if expenditures for the equipment had not been made. The Company capitalized interest of $ 119,000 and $ 110,000 in 2020 and 2019, respectively, as costs of medical equipment. The Company leases Gamma Knife and radiation therapy equipment to its customers under arrangements accounted for as operating leases. At December 31, 2020, the Company held equipment under operating lease contracts with customers with an original cost of $ 75,241,000 and accumulated depreciation of $ 45,416,000 . At December 31, 2019, the Company held equipment under operating lease contracts with customers with an original cost of $ 92,135,000 and accumulated depreciation of $ 55,148,000 . As of December 31, 2020, the Company recognized a loss on the write down of impaired assets of $ 8,264,000 . The impaired assets included six ( 6 ) Gamma Knife units and the Company's deposits towards purchase of proton beam systems and related capitalized interest. See further discussion under Note 2 - Long-lived asset impairment and Note 3 - Property and Equipment for further discussion. Fair value of financial instruments – The Company’s disclosures of the fair value of financial instruments is based on a fair value hierarchy which prioritizes the inputs to the valuation techniques used to measure fair value into three levels. Level 1 inputs are unadjusted quoted market prices in active markets for identical assets and liabilities that the Company has the ability to access at the measurement date. Level 2 inputs are inputs other than quoted prices within Level 1 that are observable for the asset or liability, either directly or indirectly. Level 3 inputs are unobservable inputs for assets or liabilities, and reflect the Company’s own assumptions about the assumptions that market participants would use in pricing the asset or liability. The estimated fair value of the Company’s assets and liabilities as of December 31, 2020 and 2019 were as follows (in thousands): Level 1 Level 2 Level 3 Total Carrying Value December 31, 2020 Assets: Cash, cash equivalents, restricted cash $ 4,325 $ — $ — $ 4,325 $ 4,325 Total $ 4,325 $ — $ — $ 4,325 $ 4,325 Liabilities Debt obligations $ — $ — $ 4,662 $ 4,662 $ 4,624 Total $ — $ — $ 4,662 $ 4,662 $ 4,624 December 31, 2019 Assets: Cash, cash equivalents, restricted cash $ 1,779 $ — $ — $ 1,779 $ 1,779 Total $ 1,779 $ — $ — $ 1,779 $ 1,779 Liabilities Debt obligations $ — $ — $ 3,075 $ 3,075 $ 3,480 Total $ — $ — $ 3,075 $ 3,075 $ 3,480 F- 13 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 2 – A CCOUNTING P OLICIES (CONTINUED) Revenue recognition - The Company recognizes revenues under ASC 842 Leases (“ASC 842”) and ASC 606 Revenue from Contracts with Customers (“ASC 606”). Rental income from medical services – The Company recognizes revenues under ASC 842 when services have been rendered and collectability is reasonably assured, on either a fee per use or revenue sharing basis. The terms of the contracts do not contain any guaranteed minimum payments. The Company’s contracts are typically for a 10 -year term and are classified as either fee per use or retail. Retail arrangements are further classified as either turn-key or revenue sharing. Revenues from fee per use contracts is determined by each hospital’s contracted rate. Revenues are recognized at the time the procedures are performed, based on each hospital’s contracted rate and the number of procedures performed. Under revenue sharing arrangements, the Company receives a contracted percentage of the reimbursement received by the hospital. The amount the Company expects to receive is recorded as revenue and estimated based on historical experience. Revenue estimates are reviewed periodically and adjusted as necessary. Under turn-key arrangements, the Company receives payment from the hospital in the amount of the hospital’s reimbursement from third party payors, and the Company is responsible for paying all the operating costs of the equipment. Operating costs are determined primarily based on historical treatment protocols and cost schedules with the hospital. The Company records an estimate of operating costs which are reviewed on a regular basis and adjusted as necessary to more accurately reflect the actual operating costs. For turn-key sites, the Company also shares a percentage of net operating profit. The Company records an estimate of net operating profit based on estimated revenues, less estimated operating costs. The operating costs and estimated net operating profit are recorded as other direct operating costs in the consolidated statement of operations . As of December 31, 2020 and 2019, the Company recognized revenues of approximately $ 16,204,000 and $ 19,396,000 under ASC 842, respectively. Patient income – The Company has stand-alone facilities in Lima, Peru and Guayaquil, Ecuador, where a contract exists between the Company’s facilities and the individual patient treated at the facility. Under ASC 606, the Company acts as the principal in this transaction and provides, at a point in time, a single performance obligation, in the form of a Gamma Knife treatment. Revenue related to a Gamma Knife treatment is recognized on a gross basis at the time when the patient receives treatment. There is no variable consideration present in the Company’s performance obligation and the transaction price is agreed upon per the stated contractual rate. GKPeru's payment terms are typically prepaid for self-pay patients and insurance provider payments are paid net 30 days. GKCE's patient population is primarily covered by a government payor and payments are paid approximately 30 to 60 days upon invoice. The Company did not capitalize any incremental costs related to the fulfillment of its customer contracts. Accounts receivable earned by GKPeru were not significant for the year ended December 31, 2020 and 2019. GKCE's accounts receivable were $ 467,000 for the year ended December 31, 2020. As of December 31, 2020 and 2019, the Company recognized revenues of approximately $ 1,633,000 and $ 1,209,000 under ASC 606, respectively. Stock-based compensation – The Company measures all stock-based compensation awards at fair value and records such expense in its consolidated financial statements over the requisite service period of the related award. See Note 9 for additional information on the Company’s stock-based compensation programs. Costs of revenue – The Company's costs of revenue consist primarily of maintenance and supplies, depreciation and amortization, and other operating expenses (such as insurance, property taxes, sales taxes, marketing costs and operating costs from the Company’s retail sites). Costs of revenues are recognized as incurred. Sales and Marketing – The Company markets its services through its preferred provider status with Elekta and a direct sales effort led by its Senior Vice President of Sales and Business Development, its President and Chief Financial and Operating Officer and its Chief Executive Officer (“CEO”). The Company typically provides the equipment, as well as planning, installation, reimbursement and marketing support services. Income taxes – The Company accounts for income taxes using the asset and liability method. Under this method, deferred tax assets and liabilities are determined based on differences between the financial reporting and tax bases of assets and liabilities and are measured using the enacted tax rates and laws that will be in effect when the differences are expected to reverse. F- 14 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 2 – A CCOUNTING P OLICIES (CONTINUED) The Company accounts for uncertainty in income taxes as required by the provisions of ASC 740 Income taxes (“ASC 740”), which clarifies the accounting for uncertainty in income taxes recognized in an enterprise’s financial statements. The first step is to evaluate the tax position for recognition by determining if the weight of available evidence indicates that it is more likely than not that the position will be sustained on audit, including resolution of related appeals or litigation processes, if any. The second step is to estimate and measure the tax benefit as the largest amount that is more than 50 % likely of being realized upon ultimate settlement. It is inherently difficult and subjective to estimate such amounts, as this requires the Company to determine the probability of various possible outcomes. The Company considers many factors when evaluating and estimating the Company’s tax positions and tax benefits, which may require periodic adjustments and may not accurately anticipate actual outcomes. See Note 8 for further discussion on income taxes. Functional currency – Based on guidance provided in accordance with ASC 830, Foreign Currency Matters (“ASC 830”), the Company analyzes its operations outside the United States to determine the functional currency of each operation. Management has determined that these operations are initially accounted for in U.S. dollars since the primary transactions incurred are in U.S. dollars and the Company provides significant funding towards the startup of the operation. When Management determines that an operation has become predominantly self-sufficient, the Company will change its accounting for the operation to the local currency from the U.S. dollar. The Company analyzed it’s Gamma Knife site in Peru under ASC 830 as of December 31, 2020 and 2019 and concluded the functional currency was the U.S. dollar. As facts and circumstances change, the Company will revisit this conclusion. Asset Retirement Obligations – Based on the guidance provided in ASC 410 Asset Retirement Obligations (“ASC 410”), the Company analyzed its existing lease agreements and determined an asset retirement obligation (“ARO”) exists to remove the respective units at the end of the lease terms. As of December 31, 2020, four ( 4 ) of the Company's Gamma Knife customers notified the Company of their intent to terminate their contracts at the contract lease term. The Company recorded an ARO liability for these four ( 4 ) sites, using estimates from Elekta. No liability has been recorded as of December 31, 2020 for the remaining Gamma Knife sites, or as of December 31, 2019, because it is uncertain these units will be removed and the Company historically has not removed the Gamma Knife equipment at the end of the lease term. The Company will re-evaluate the need to record additional ARO liabilities on a periodic basis when facts and circumstances change that could affect this conclusion. Earnings per share – Basic earnings per share excludes dilution and is computed by dividing income available to common shareholders by the weighted average number of common shares outstanding for the year. The fully vested restricted stock units not issued and outstanding, are also included therein. Diluted earnings per share reflect the potential dilution that could occur if common shares were issued pursuant to the exercise of options or warrants. Because the Company reported a loss for the year ended December 31, 2020, the potentially dilutive effects of approximately 13,000 , of the Company's unvested restricted stock awards were not considered for the reporting periods. On March 31, 2020, the Company’s Award Agreements (as defined below) expired and the unvested performance share awards were returned to the Company’s stock incentive plan - see Note 9 for further discussion. Based on the guidance provided in accordance with ASC 260, the weighted average common shares for basic earnings per share, for the year ended December 31, 2019 excluded the weighted average impact of the unvested performance share awards. These awards were legally outstanding but not deemed participating securities and therefore were excluded from the calculation of basic earnings per share. The unvested shares were also excluded from the denominator for diluted earnings per share because they were considered contingent shares not deemed probable as of December 31, 2019. The following table illustrates the computations of basic and diluted earnings per share for the years ended December 31, 2020 and 2019. F- 15 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 2 – A CCOUNTING P OLICIES (CONTINUED) 2020 2019 Numerator for basic and diluted (loss) earnings per share $ ( 7,058,000 ) $ 659,000 Denominator: Denominator for basic and diluted (loss) earnings per share – weighted-average shares 6,182,000 5,919,000 Effect of dilutive securities Employee stock options and restricted stock — 11,000 Denominator for diluted (loss) earnings per share – adjusted weighted-average shares 6,182,000 5,930,000 (Loss) earnings per common share- basic $ ( 1.14 ) $ 0.11 (Loss) earnings per common share- diluted $ ( 1.14 ) $ 0.11 In 2020, options outstanding to purchase 406,000 shares of common stock at an exercise price range of $ 2.25 - $ 3.90 per share and 13,000 restricted stock units were not included in the calculation of diluted earnings per share because they would be anti-dilutive. In 2019, options outstanding to purchase 387,000 shares of common stock at an exercise price range of $ 2.68 - $ 3.90 per share and 3,000 restricted stock units were not included in the calculation of diluted earnings per share because they would be anti-dilutive. Business segment information - Based on the guidance provided in accordance with ASC 280 Segment Reporting (“ASC 280”), the Company analyzed its subsidiaries which are all in the business of leasing radiosurgery and radiation therapy equipment to healthcare providers, and concluded there are two reportable segments, domestic and foreign. The Company provides Gamma Knife and PBRT equipment to fifteen hospitals in the United States and owns and operates two single-unit facilities in Lima, Peru and Guayaquil, Ecuador as of December 31, 2020. The Company determined two reportable segments existed due to similarities in economics of business operations and geographic location. The operating results of the two reportable segments are reviewed by the Company’s CEO and President, Chief Operating and Financial Officer, who are also deemed the Company’s Chief Operating Decision Makers (“CODMs”). As of December 31, 2019, the Company had one reportable segment. Following the Company's acquisition of GKCE in June 2020, the Company concluded it had two reportable segments. The revenues, profit or loss, and net property and equipment allocations for the Company's two reportable segments as of December 31, 2020 consists of the following: 2020 2019 Revenues Domestic $ 16,204,000 $ 19,396,000 Foreign 1,633,000 1,209,000 Total $ 17,837,000 $ 20,605,000 2020 2019 Profit or (loss) Domestic $ ( 7,082,000 ) $ 769,000 Foreign 24,000 ( 110,000 ) Total $ ( 7,058,000 ) $ 659,000 2020 2019 Property and equipment, net Domestic $ 27,223,000 $ 38,593,000 Foreign 3,195,000 2,887,000 Total $ 30,418,000 $ 41,480,000 F- 16 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 2 – A CCOUNTING P OLICIES (CONTINUED) Long lived asset impairment – The Company assesses the recoverability of its long-lived assets when events or changes in circumstances indicate their carrying value may not be recoverable. Such events or changes in circumstances may include: a significant adverse change in the extent or manner in which a long-lived asset is being used, significant adverse change in legal factors or in the business climate that could affect the value of a long-lived asset, an accumulation of costs significantly in excess of the amount originally expected for the acquisition or development of a long-lived asset, current or future operating or cash flow losses that demonstrate continuing losses associated with the use of a long-lived asset, or a current expectation that, more likely than not, a long-lived asset will be sold or otherwise disposed of significantly before the end of its previously estimated useful life. The Company performs impairment testing at the asset group level that represents the lowest level for which identifiable cash flows are largely independent of the cash flows of other assets and liabilities. The Company assesses recoverability of a long-lived asset by determining whether the carrying value of the asset group can be recovered through projected undiscounted cash flows over their remaining lives. If the carrying value of the asset group exceeds the forecasted undiscounted cash flows, an impairment loss is recognized, measured as the amount by which the carrying amount exceeds estimated fair value. An impairment loss is charged to the consolidated statement of operations in the period in which management determines such impairment. As of December 31, 2020, the Company determined circumstances existed indicating its assets could be impaired, concluded an impairment existed, and recognized a loss on the write down of impaired assets of $ 8,264,000 . No such impairment has been noted as of December 31, 2019. See Note 3 - Property and Equipment for further discussion. Goodwill and intangible assets - The Company recorded goodwill of $ 1,265,000 and an intangible asset with a fair value of $ 78,000 as part of the Acquisition in June 2020. The intangible asset identified was GKCE's trade name and the Company assigned an indefinite useful life to the asset. Based on the guidance provided in accordance with ASC 350 Intangibles-Goodwill and Other (“ASC 350”), the Company does not amortize the intangible asset because it has an indefinite life. The Company assesses goodwill at the reporting unit level, which has been determined to be GKCE. Each reporting period, the Company assesses whether events or circumstances continue to support an indefinite useful life for the intangible asset. Per ASC 350, the Company tests goodwill and intangibles for impairment annually or as events or circumstances change that indicate the fair value may be below the carrying amount. As of December 31, 2020, there has been no change to the Company's assessment of the value of intangible assets or goodwill. Acquisitions - The Company records acquisitions according to ASC 805 Business Combinations (“ASC 805”) using the acquisition method of accounting. Under the acquisition method of accounting, all assets acquired, including goodwill and other intangible assets, should be stated at fair value at the time of acquisition. The allocation of purchase price consideration is preliminary, pending the completion of the fair value of certain tangible, intangible assets, and residual goodwill. During the measurement period, which can be no more than one year from the Closing Date, the Company expects to continue to obtain information to assist in determining the final fair value of assets acquired. See Note 4 - GKCE Acquisition for further discussion on acquisitions. Accounting pronouncement issued and adopted – In February 2018, the FASB issued ASU No. 2018-03 Recognition and Measurement of Financial Assets and Financial Liabilities (“ASU 2018-03”), which clarifies certain aspects of ASU 2016-1. These are: equity securities without a readily determinable fair value – discontinuation, equity securities without a readily determinable fair value – adjustments, forward contracts and purchased options, presentation requirements for certain fair value option liabilities, fair value option liabilities denominated in a foreign currency, and transition guidance for equity securities without a readily determinable fair value. In August 2018, the FASB issued ASU No. 2018-13 Fair Value Measurement (Topic 820): Disclosure Framework – Changes to the Disclosure Requirements to Fair Value Measurement (“ASU 2018-13”), which amended the effective date and other certain measurement aspects of ASU 2018-03. The new guidance is effective for fiscal years and interim periods within those fiscal years beginning after December 15, 2019. The Company adopted ASU 2018-03 and ASU 2018-13 on January 1, 2020. There was no significant impact on its consolidated financial statements and related disclosures. Accounting pronouncement issued and not yet adopted – In December 2019, the FASB issued ASU 2019-12 Income Taxes (Topic 740): Simplifying the Accounting for Income Taxes (“ASU 2019-12”) which removes specific exceptions to the general principles in Topic 740 and eliminates the need for an organization to analyze whether the following apply in a given period: exception to the incremental approach for intraperiod tax allocation; exceptions to accounting for basis differences when there are ownership changes in foreign investments; exception in interim period income tax accounting for year-to-date losses that exceed anticipated losses. The new guidance is effective for fiscal years and interim periods beginning after December 15, 2020. The Company is currently evaluating ASU 2019-12 to determine the impact it may have on its consolidated financial statements. F- 17 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 3 – P ROPERTY AND E QUIPMENT Property and equipment consists of the following: DECEMBER 31, 2020 2019 Medical equipment and facilities $ 75,657,000 $ 92,132,000 Office equipment 330,000 594,000 Construction in progress 170,000 1,965,000 Deposits towards purchase of proton beam systems — 2,250,000 76,157,000 96,941,000 Accumulated depreciation ( 45,739,000 ) ( 55,461,000 ) Net property and equipment $ 30,418,000 $ 41,480,000 As of December 31, 2020, approximately $ 3,195,000 of the net property and equipment balance is outside of the United States. As December 31, 2020, the Company recognized a loss on the write down of impaired assets of $ 8,264,000 . The impaired assets included six ( 6 ) Gamma Knife units and related removal costs, and two ( 2 ) deposits towards the purchase of proton beam systems and related capitalized interest. The six ( 6 ) Gamma Knife units that were impaired consisted of two ( 2 ) units that had been taken out of service in prior years, one ( 1 ) unit that was taken out of service in 2020 and three ( 3 ) units that have already been, or the Company anticipates will be, taken out of service in 2021 , totaling $ 3,051,000 . In addition to this impairment write-off of $ 3,051,000 were estimated costs of de-install and removal (ARO) of four ( 4 ) of the Gamma Knife units of $ 1,350,000 (of which, the Company has paid $ 80,000 ) as of December 31, 2020. Total impairment related to the Gamma Knife business was $ 4,401,000 for the year ended December 31, 2020. The Company reviews the carrying value of its long-lived assets for impairment on a quarterly basis, or as events or circumstances might indicate that the carrying value may not be recoverable. The Company has reviewed its Gamma Knife equipment, in light of available information as of December 31, 2020 and based on current customer prospects, the probability of future contract extensions or renewals, and the high turnover rate in contract terminations compared to the Company's historical contract termination rate, the Company determined that these six ( 6 ) Gamma Knife units were more-than temporarily impaired. Prior to December 31, 2020, the Company had $ 2,250,000 in deposits toward the purchase of two MEVION S250i PBRT systems from Mevion. The Company reviews the carrying value of its deposits for impairment on a quarterly basis, or as events or circumstances might indicate that the carrying value may not be recoverable. The Company has reviewed the deposits, in light of available information, as of December 31, 2020 and based on its current customer prospects, the impact that the COVID-19 pandemic has had on medical centers undertaking large capital expenditure projects for a limited patient base, and the length of time required to negotiate and implement a proton therapy project, the Company determined that its deposits of $ 2,250,000 , related capitalized interest and other charges of $ 1,613,000 were other-than temporarily impaired. Total impairment related to the proton therapy business was $ 3,863,000 . F- 18 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 4 - GKCE ACQUISITION On June 18, 2019, the Company entered into a Stock Purchase Agreement to acquire Gamma Knife Center Ecuador S.A. (“GKCE”) from GKCE’s selling majority shareholders. GKCE is a well-established Gamma Knife operation founded in 2009 as a private clinic to introduce advanced stereotactic radiosurgery into Ecuador and continues to operate the only Gamma Knife unit in the country. The Company acquired GKCE for the continued expansion of its business internationally. On June 12, 2020 (the “Closing Date”), the Company acquired approximately 98 % of the total outstanding shares of GKCE. As of December 31, 2020, the Company acquired approximately 99.3 % of the total outstanding shares of GKCE and intends to acquire the remaining 0.7 % at a later date. The fair value of the non-controlling interests (“NCI”) on the Closing Date was approximately $ 58,000 , which was consistent with the purchase price in the executed NCI agreements. The total purchase consideration for 100 % of the outstanding shares of GKCE was $ 2,883,000 , including $ 2,000,000 of base purchase price, subject to certain price adjustments for current assets and liabilities and tax withholding. The base purchase price of $ 2,000,000 was paid with $ 575,000 of cash and a $ 1,425,000 loan from the United States International Development Finance Corporation (“DFC”). The DFC loan is denominated in U.S. dollars, which is also the currency of Ecuador. The price adjustments will be paid by the Company in the post-closing period with the adjustments related to the amount of working capital that GKCE had as of the Closing Date. The first price adjustment for working capital as of the Closing Date was approximately $ 515,000 , which was paid by the Company in August 2020. As of December 31, 2020, the Company owed the withholding taxes related to this payment totaling approximately $ 43,000 . The Company estimates an additional contingent consideration of approximately $ 368,000 will be remitted to the seller based on the collection of Closing Date accounts receivable balances, net of related costs, during the three-month, six-month and twelve-month periods after the Closing Date. As of December 31, 2020, $ 214,000 of the contingent considerations had been paid and $ 154,000 is estimated to be paid for the twelve-month period after the Closing Date. The Company reviewed historical patient treatments, invoice, and collection data from GKCE to determine an appropriate estimate of the contingent consideration at the Closing Date. The acquisition has been accounted for according to ASC 805 using the acquisition method of accounting. Under the acquisition method of accounting, all assets acquired, including goodwill and other intangible assets, should be stated at fair value at the time of acquisition. The allocation of purchase price consideration is preliminary, pending the completion of the fair value of certain tangible, intangible assets, and residual goodwill. During the measurement period, which can be no more than one year from the Closing Date, the Company expects to continue to obtain information to assist in determining the final fair value of assets acquired. The assets acquired were recorded based on valuations derived from estimated fair value assessments and assumptions used by the Company. Thus, the provisional measurements of fair value discussed below are subject to change. As of December 31, 2020, accounting for the Closing Date accounts receivable balances, allowance on the uncollected accounts receivable balances, and related liabilities, was not complete. The accounting for these amounts will be complete following the twelve-month period after the Closing Date, per the terms of the Stock Purchase Agreement. The Company expects to finalize the valuation as soon as practicable, but no later than one year from the Closing Date. While the Company believes its estimates and assumptions underlying the valuations are reasonable, different estimates and assumptions could result in different valuations assigned to the individual assets acquired, and the resulting amount of goodwill. After the Acquisition date, the Company received additional information regarding the amounts recorded as accounts receivable as of June 12, 2020. After reviewing the information obtained, the Company booked an additional $ 27,000 of accounts receivable as of December 31, 2020. As a result, related liabilities were increased by $ 13,000 and the contingent consideration increased by $ 14,000 . There was no impact to goodwill or net loss as of December 31, 2020. F- 19 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 4 - GKCE ACQUISITION (CONTINUED) The fair value of assets acquired and liabilities assumed were as follows: June 12, 2020 Cash and cash equivalents $ 432,000 Accounts receivable 854,000 Prepaid expense and other 22,000 Building 385,000 Land 19,000 Medical equipment 319,000 Purchased intangible assets 78,000 Goodwill 1,265,000 Total assets acquired $ 3,374,000 Accounts payable $ ( 193,000 ) Income taxes payable ( 141,000 ) Deferred income taxes ( 66,000 ) Employee compensation and benefits ( 91,000 ) Total liabilities assumed ( 491,000 ) Consideration allocated to assets acquired and liabilities assumed $ 2,883,000 First working capital payment $ ( 515,000 ) Estimated subsequent working capital payment ( 368,000 ) Base purchase consideration $ 2,000,000 The Company has allocated the purchase price of GKCE to the tangible assets, liabilities, and intangible asset acquired, based on their estimated fair values. Goodwill represents the excess of the purchase price consideration over the fair value of the identifiable tangible and intangible assets assumed. The Company believes the amount of goodwill resulting from the acquisition is primarily attributable to expected synergies from an assembled and trained workforce and enhanced opportunities for growth and innovation. The goodwill resulting from the acquisition is not tax deductible. The preliminary value of the acquired tangible assets acquired are as follows: Fair Value Useful Life (in Years) Building $ 385,000 20 Land 19,000 Medical equipment 302,000 2 Other fixed assets 17,000 2 Total tangible assets $ 723,000 The Company also acquired intangible assets with a fair value of $ 78,000 . The intangible asset identified was GKCE's trade name and the Company assigned an indefinite useful life to the asset. The Company incurred costs related to the acquisition of approximately $ 93,000 for the three-month period ended June 30, 2020 and $ 69,000 for the three-month period ended September 30, 2020. All acquisition related costs were expensed as incurred and have been recorded in selling and administrative expense in the Company's consolidated statement of operations. F- 20 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 4 - GKCE ACQUISITION (CONTINUED) The revenue and earnings of GKCE have been included in the Company’s consolidated results since the Closing Date and are not material to the Company’s consolidated financial results. Historical financial statements and pro forma results of the operations of GKCE as if the Acquisition occurred earlier than the Closing Date have not been presented, as the applicable significance thresholds are not exceeded by the Acquisition and the corresponding requirements to provide historical financial statements and corresponding pro forma financial information are not applicable to the Acquisition. In addition, the Company believes that the financial impact of the Acquisition to the Company’s consolidated financial statements is not material and such historical financial information and pro forma financial information would not be meaningful for investors and financial statement users. F- 21 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 5 - LONG TERM DEBT Long-term debt consists primarily of seven notes with three financing companies collateralized by the Gamma Knife equipment having an aggregate net book value of $ 11,023,000 , the individual customer contracts, and related accounts receivable of $ 1,718,000 at December 31, 2020. These notes are predominantly payable in 36 to 84 fully amortizing monthly installments, mature between January 2021 and September 2027. The notes accrue interest at fixed annual rates between 3.67 % and 6.90 %. As of December 31, 2019, the Company had six notes with two financing companies collateralized by the Gamma Knife equipment having an aggregate net book value of $ 13,130,000 , the individual customer contracts, and related accounts receivable of $ 1,848,000 . The following are contractual maturities of long-term debt by year at December 31, 2020, excluding debt issuance costs of $ 27,000 : Year ending December 31, Principal 2021 $ 1,157,000 2022 768,000 2023 802,000 2024 839,000 2025 592,000 Thereafter 466,000 $ 4,624,000 F- 22 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 6 - FINANCE LEASES The Company has six finance lease obligations with two financing companies, collateralized by Gamma Knife and PBRT equipment having an aggregate net book value of $ 18,093,000 , the individual customer contracts, and related accounts receivable of $ 1,892,000 at December 31, 2020. These obligations have imputed interest rates ranging between 4.73 % and 13.00 %, are predominantly payable in 36 to 84 monthly installments, and mature between November 2021 and September 2024. As of December 31, 2019, the Company had ten finance lease obligations with three financing companies, collateralized by Gamma Knife and PBRT equipment, having an aggregate net book value of $ 22,860,000 , the individual customer contracts, and related accounts receivable of $ 4,600,000 . At the end of each lease term, the Company has a bargain purchase option to purchase the equipment. Future minimum lease payments, together with the present value of the net minimum lease payments under finance leases at December 31, 2020, are summarized as follows: Net Present Value of Minimum Lease Payments Year ending December 31, 2021 $ 6,590,000 2022 1,576,000 2023 1,083,000 2024 522,000 Total finance lease payments 9,771,000 Less imputed interest 852,000 8,919,000 Less current portion 5,945,000 $ 2,974,000 F- 23 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 7 - LEASES The Company determines if a contract is a lease at inception. Under ASC 842, the Company is a lessor of equipment to various customers. Leases that commenced prior to ASC 842 adoption date were classified as operating leases under historical guidance. As the Company has elected the package of practical expedients allowing it to not reassess lease classification, these leases are classified as operating leases under ASC 842 as well. All of the Company’s lessor arrangements entered into after ASC 842 adoption are also classified as operating leases. Some of these lease terms have an option to extend the lease after the initial term, but do not contain the option to terminate early or purchase the asset at the end of the term. The Company’s Gamma Knife and PBRT contracts with hospitals are classified as operating leases under ASC 842. The related equipment is included in medical equipment and facilities on the Company’s consolidated balance sheets (see further discussion at Note 2). As all income from the Company’s lessor arrangements is solely based on procedure volume, all income is considered variable payments not dependent on an index or a rate. As such, the Company does not measure future operating lease receivables. The Company’s lessee operating leases are accounted for as right-of-use (“ROU”) assets, other current liabilities, and lease liabilities on the consolidated balance sheets. Operating lease ROU assets and liabilities are recognized based on the present value of the future minimum lease payments over the lease term at commencement date. The Company’s operating lease contracts do not provide an implicit rate for calculating the present value of future lease payments, so the Company determined its incremental borrowing rate to be in the range of approximately 4.0 % and 6.0 % by using available market rates and expected lease terms. The operating lease ROU assets and liabilities also include any lease payments made and excludes lease incentives and initial direct costs incurred. Lease expense for minimum lease payments is recognized on a straight-line basis over the lease term. The Company’s lessee operating lease agreements are for administrative office space and related equipment, and the agreement to lease clinic space for its stand-alone facility in Lima, Peru. These leases have remaining lease terms between 2 and 3 years, some of which include options to renew or extend the lease. As of December 31, 2020, operating ROU assets and liabilities were $ 886,000 . During the year ended December 31, 2020, the Company elected to not renew its lease for a satellite office in Fairfield, California. The Company previously included the renewal term in its assessment of the lease term for the ROU asset and liability. The Company accounted for this change as a lease reassessment under ASC 842. At the reassessment date, the remaining lease balance was not material to the Company's consolidated balance sheets and the Company wrote off the related ROU assets and liabilities of $ 67,000 . Also during the year ended December 31, 2020, the Company agreed to a rent increase for its clinic space for its stand-alone facility in Lima, Peru. The rent increase was effective as of January 1, 2020 and the Company increased the related ROU assets and liabilities by $ 135,000 . The following table summarizes maturities of lessee operating lease ROU assets and liabilities as of December 31, 2020: Year ending December 31, Operating Leases 2021 346,000 2022 353,000 2023 248,000 2024 8,000 Total lease payments 955,000 Less imputed interest ( 69,000 ) Total $ 886,000 F- 24 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 8 – I NCOME T AXES As of December 31, 2020 and 2019 the Company recorded an income tax benefit of $ 1,737,000 and income tax expense of $ 128,000 , respectively. The decrease in the Company’s provision for income taxes as of December 31, 2020 is due to a loss on the write down of impaired assets. The components of the provision (benefit) for income taxes as of December 31, 2020 and 2019 consist of the following: YEARS ENDED DECEMBER 31, 2020 2019 Current: Federal $ 209,000 $ 443,000 State 88,000 207,000 Foreign 117,000 130,000 Total current 414,000 780,000 Deferred: Federal ( 1,909,000 ) ( 311,000 ) State ( 266,000 ) ( 251,000 ) Foreign 24,000 ( 90,000 ) Total deferred ( 2,151,000 ) ( 652,000 ) $ ( 1,737,000 ) $ 128,000 Significant components of the Company’s deferred tax liabilities and assets as of December 31, 2020 and 2019 are as follows: DECEMBER 31, 2020 2019 Deferred tax liabilities: Property and equipment $ ( 564,000 ) $ ( 3,112,000 ) Total deferred tax liabilities ( 564,000 ) ( 3,112,000 ) Deferred tax assets: Net operating loss carryforwards 99,000 117,000 Accruals and allowances 43,000 248,000 Tax credits 5,000 4,000 Other – net 50,000 229,000 Capital loss carryover 627,000 921,000 Total deferred tax assets 824,000 1,519,000 Valuation allowance ( 678,000 ) ( 921,000 ) Deferred tax assets net of valuation allowance 146,000 598,000 Net deferred tax liabilities $ ( 418,000 ) $ ( 2,514,000 ) F- 25 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 8 – I NCOME T AXES (CONTINUED) These amounts are presented in the financial statements as follows: DECEMBER 31, 2020 2019 Deferred income taxes (non-current) $ ( 418,000 ) $ ( 2,514,000 ) $ ( 418,000 ) $ ( 2,514,000 ) The (benefit) provision for income taxes differs from the amount computed by applying the U.S. federal statutory tax rate ( 21 % in 2020 and 2019) to income before taxes as follows: YEARS ENDED DECEMBER 31, 2020 2019 Computed expected federal income tax $ ( 1,844,000 ) $ 167,000 State income taxes, net of federal benefit ( 199,000 ) ( 80,000 ) Non-deductible expenses 6,000 29,000 Return to Provision True-up 22,000 39,000 Uncertain Tax Positions 16,000 80,000 Capital loss carryforward expiration 246,000 — Change in valuation allowance ( 243,000 ) ( 175,000 ) Other deferred tax adjustments 259,000 68,000 $ ( 1,737,000 ) $ 128,000 At December 31, 2020, the Company exhausted the remainder of its net operating loss carryforward for federal income tax return purposes. The Company has net operating loss carryforwards for state income tax purposes of approximately $ 2,219,000 that begin to expire in 2029. The Company has net operating loss carryforwards for its international subsidiaries of approximately $ 32,000 . Utilization of the net operating loss and credit carryforwards may be subject to an annual limitation due to the ownership change limitations provided by the Internal Revenue Code of 1986, as amended (the “Code”), and similar state provisions. Any annual limitation may result in the expiration of net operating losses and credits before utilization. At December 31, 2020, the Company has a capital loss carryforward for federal income tax return purposes of approximately $ 2,586,000 which starts to expire in 2021. The Company has capital loss carryforwards for state income tax purposes of approximately $ 129,000 which starts to expire in 2021. Due to uncertainty surrounding the realization of impairment losses, capital losses and foreign operating losses in future years, the Company has placed a valuation allowance against a portion of its net domestic and foreign deferred tax assets. The net valuation allowance decreased by $ 243,000 and $ 175,000 for the tax years ended December 31, 2020 and 2019, respectively. During the year ended December 31, 2019, the Company released the valuation allowance related to GKPeru deferred tax assets, which resulted in an income tax benefit of $ 104,000 . The Company concluded, based upon the preponderance of positive evidence (i.e. cumulative profit before tax adjusted for permanent items over the previous twelve quarters, a history of taxable income in recent periods, and the current forecast of income before taxes for GKPeru going forward) over negative evidence and the anticipated ability to use the deferred tax assets, that it was more likely than not that the deferred tax assets will be realized. If there are unfavorable changes to actual operating results or to projections of future income, the Company may determine that it is more likely than not such deferred tax assets may not be realizable. The tax return years 2016 through 2019 remain open to examination by the major domestic taxing jurisdictions to which the Company is subject. In 2019, the Company settled a New York State examination for tax years 2015 through 2017 with no material adjustments. Net operating losses generated on a tax return basis by the Company for calendar years 1999 through 2004, 2009, 2010, 2012, 2014, 2015, 2016, 2017 and 2018 remain open to examination by the major domestic taxing jurisdictions. F- 26 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 8 – I NCOME T AXES (CONTINUED) The Company has adopted accounting standards which prescribe a recognition threshold and measurement attribute for the financial statement recognition and measurement of uncertain tax positions taken or expected to be taken in a company's income tax return, and also provides guidance on derecognition, classification, interest and penalties, accounting in interim periods, disclosure, and transition. Additionally, these accounting standards specify that tax positions for which the timing of the ultimate resolution is uncertain should be recognized as long-term liabilities. The Company has made no reclassifications between current taxes payable and long term taxes payable under this guidance. As of December 31, 2020, the unrecognized tax benefit was $ 275,000 which, if recognized, will not affect the annual effective tax rate as these unrecognized tax benefits would increase deferred tax assets which would be subject to a full valuation allowance. A reconciliation of the beginning and ending amount of unrecognized tax benefit is as follows: YEARS ENDED DECEMBER 31, 2020 2019 Balance at beginning of year $ 259,000 $ 87,000 Additions based on tax positions of prior years 16,000 172,000 Balance at end of year $ 275,000 $ 259,000 The Company's policy for deducting interest and penalties is to treat interest as interest expense and penalties as taxes. As of December 31, 2020, the Company had $ 15,000 accrued for the payment of penalties and zero interest related to unrecognized tax benefits. The Company does not expect any material changes to our uncertain tax positions within the next 12 months. N OTE 9 – S TOCK-BASED COMPENSATION EXPENSE Incentive Compensation Plan In June 2010 shareholders approved an amendment and restatement of the Company’s stock incentive plan, renaming it the Incentive Compensation Plan (the “Plan”), and among other things, increasing the number of shares of the Company’s common stock reserved for issuance under the Plan to 1,630,000 . The Plan provides that the shares reserved under the Plan are available for issuance to officers of the Company, other key employees, non- employee directors, and advisors. The Plan is a successor to the Company’s previous plans, and any shares awarded and outstanding under those plans were transferred to the Plan. No further grants or share issuances will be made under the previous plans. On June 21, 2019, the Company’s shareholders approved an amendment and restatement of the Plan in order to extend the term of the Plan by two years to February 22, 2022. As of December 31, 2020, approximately 437,000 shares remain available for grant under the Plan. Under the Plan, a total of 456,000 restricted stock units have been granted, consisting of 43,000 of annual automatic grants to non-employee directors and the corporate secretary, 293,000 of deferred retainer fees to non-employee members of the Board, 20,000 grants issued in lieu of commission, to two ( 2 ) employees of the Company and 100,000 restricted stock units issued to the CEO during 2020, see further discussion below. Of the total restricted stock units granted under the Plan 210,000 of them are fully vested but not yet deemed issued and outstanding, 233,000 are fully vested and outstanding, and 13,000 are outstanding as of December 31, 2020. F- 27 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 9 – S TOCK-BASED COMPENSATION EXPENSE (CONTINUED) Changes in restricted stock units, consisting primarily of annual automatic grants, deferred compensation to non-employee directors, and restricted stock units awards to the CEO, under the Incentive Compensation Plans during 2020 and 2019 are as follows: Restricted Stock Units Grant Date Weighted- Average Fair Value Intrinsic Value Outstanding at January 1, 2019 4,000 $ 2.68 $ — Granted 36,000 $ 2.50 $ — Vested ( 37,000 ) $ 2.47 $ — Outstanding at December 31, 2019 3,000 $ 3.03 $ — Granted 144,000 $ 1.96 $ — Vested ( 134,000 ) $ 1.98 $ — Outstanding at December 31, 2020 13,000 $ 1.97 $ 2,000 For the year ended December 31, 2020, total compensation expense recorded in the consolidated statements of operations related to restricted stock units in lieu of retainer fees was $ 80,000 . For the year ended December 31, 2020, total compensation expense recorded in the consolidated statements of income for annual restricted stock units awarded was $ 7,000 , with an offsetting tax benefit of $ 1,000 , as this expense is deductible for income tax purposes. As of December 31, 2020, there was $ 2,000 of total unrecognized compensation cost related to annual restricted stock units which is expected to be recognized over a period of 0.5 years. During 2020 and 2019, shares of restricted stock units totaling 3,000 and 4,000 each, respectively, with a fair value of approximately $ 9,000 and $ 11,000 , respectively, vested and became unrestricted. Certain Executive Equity Awards Effective May 4, 2020, the Company appointed Raymond C. Stachowiak as Interim President and Chief Executive Officer (“Interim CEO”). As part of his Offer Letter, the Interim CEO was granted 50,000 restricted stock awards that vested in full on August 3, 2020. The Interim CEO was granted additional restricted stock awards totaling 10,000 common shares per month, which vest in full at the end of each 30 -day period following issuance. On October 1, 2020 the Interim CEO was appointed the CEO. For the year ended December 31, 2020, 100,000 restricted stock awards were issued to the CEO and 90,000 became fully vested. Additionally, Ernest R. Bates, Senior Vice President, Sales and Business Development, International Operations, was awarded 10,000 restricted stock awards, which vested in full on December 31, 2020. For the year ended December 31, 2020, total compensation expense recorded in the consolidated financial statements of operations related to executive equity awards was $ 195,000 . On January 4, 2017, the Company entered into a Performance Share Award Agreement with three executive officers of the Company (the “Award Agreements”) for 161,766 restricted stock awards which vest upon the achievement of certain performance metrics. The Award Agreements expired on March 31, 2020. Based on the guidance in ASC 718 Stock Compensation (“ASC 718”), the Company concluded these were performance-based awards with vesting criteria tied to performance metrics. As of December 31, 2017, the Company achieved one of the certain performance metrics under the Award Agreements and recognized stock compensation expense of approximately $ 108,000 related to these awards. The unrecognized stock-based compensation expense for these awards was approximately $ 421,000 and unvested restricted stock awards of approximately 129,000 were returned to the plan as of March 31, 2020. As of December 31, 2020, stock compensation expense recorded in the consolidated financial statements is summarized as follows: F- 28 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 9 – S TOCK-BASED COMPENSATION EXPENSE (CONTINUED) Stock-Based Awards Issued Compensation Award Type and Vested Expense Options — $ 17,000 RSUs Issued in Lieu of Retainer Fees — 80,000 Annual RSU Awards 3,000 7,000 Executive Compensation 100,000 195,000 Balance at of December 31, 2020 103,000 $ 299,000 Stock Options Changes in stock options outstanding under the Incentive Compensation Plans during 2020 and 2019 are as follows: Options Number of Options Weighted Average Exercise Price Weighted Average Remaining Contractual Term (Years) Aggregate Intrinsic Value Balance at December 31, 2018 613,000 $ 2.85 3.14 $ — Granted 18,000 $ 2.87 7.00 $ — Exercised ( 16,000 ) $ 2.59 — $ — Forfeited ( 165,000 ) $ 3.07 — $ — Balance at December 31, 2019 450,000 $ 2.78 2.44 $ 27,000 Granted 10,000 $ 1.88 7.00 $ — Forfeited ( 43,000 ) $ 2.54 — $ — Balance at December 31, 2020 417,000 $ 2.79 1.61 $ 2,000 Exercisable at December 31, 2019 425,000 $ 2.79 2.25 $ — Exercisable at December 31, 2020 405,000 $ 2.80 1.48 $ — The weighted average grant-date fair value of the options granted during the years 2020 and 2019 was $ 0.78 and $ 1.54 , respectively. There were no options exercised and accordingly, no intrinsic value of options exercised during the year ended December 31, 2020. There were 16,000 options exercised during the year ended December 31, 2019. Total stock-based compensation expense recognized for stock options for the years ended December 2020 and 2019 was $ 17,000 and $ 141,000 , respectively. There was no cash received from options exercised under any share-based payment arrangements for the year ended December 31, 2020, and as a result, there was no actual tax benefit realized for tax deductions from option exercises in that year. The Company received approximately $ 42,000 from the exercise of 16,000 options under the share-based arrangements for the year ended December 31, 2019. F- 29 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 9 – S TOCK-BASED COMPENSATION EXPENSE (CONTINUED) A summary of the status of the Company’s non-vested stock options as of December 31, 2020 and 2019, and changes during the years ended December 31, 2020 and 2019 is presented below: Nonvested Options Number of Options Weighted Average Grant-Date Fair Value Nonvested at December 31, 2018 125,000 $ 1.20 Granted 18,000 $ 1.54 Vested ( 118,000 ) $ 1.22 Nonvested at December 31, 2019 25,000 $ 1.40 Granted 10,000 $ 0.78 Vested ( 23,000 ) $ 1.22 Nonvested at December 31, 2020 12,000 $ 1.07 At December 31, 2020, there was approximately $ 12,000 of unrecognized compensation cost related to non-vested share-based compensation arrangements granted under the Plan. This cost is expected to be recognized over a period of approximately three years . The Company’s stock-based awards to employees are calculated using the Black-Scholes options valuation model. The Black-Scholes model was developed for use in estimating the fair value of traded options which have no vesting restrictions and are fully transferable. In addition, the Black-Scholes model requires the input of highly subjective assumptions including the expected stock price volatility. The Company’s stock-based awards have characteristics significantly different from those of traded options, and changes in the subjective input assumptions can materially affect the present value estimates. For these reasons, management believes that the existing models do not necessarily provide a reliable single measure of the fair value of its stock-based awards to employees. The fair value of the Company’s option grants issued during 2020 and 2019 were estimated using assumptions for expected life, volatility, dividend yield, forfeiture rate, and risk-free interest rate which are specific to each award as summarized in the following table. The estimated fair value of the Company’s options is amortized over the period during which the optionee is required to provide service in exchange for the award, usually the vesting period. The fair value of the Company’s option grants under the Plan in 2020 and 2019 was estimated using the following assumptions: 2020 2019 Expected life (years) 7.0 7.0 Expected forfeiture rate 0.0 % 0.0 % Expected volatility 40 % 50 % Dividend yield 0 % 0 % Risk-free interest rate 0.4 % 1.9 % Repurchase of Common Stock, Common Stock Warrants and Stock Options In 1999 and 2001, the Board of Directors approved resolutions authorizing the Company to repurchase up to a total of 1,000,000 shares of its own stock on the open market, which the Board reaffirmed in 2008. There were no shares of the Company repurchased during 2020 or 2019. There are approximately 72,000 shares remaining under this repurchase authorization. F- 30 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 10 – R ETIREMENT P LAN The Company has a defined-contribution retirement plan (the “Retirement Plan”) that allows for a matching safe harbor contribution. For 2020, the Board of Directors elected to match participant deferred salary contributions up to a maximum of 4 % of the participant’s annual compensation. Discretionary profit sharing contributions are allowed under the Retirement Plan in years that the Board does not elect a safe harbor match. The Company has accrued approximately $ 37,000 for the estimated safe harbor matching contribution for the year ended December 31, 2020. The Company contributed $ 38,000 to the Retirement Plan for the safe harbor match for the year ended December 31, 2019. F- 31 A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 11 – O PERATING L EASES The Company leases office space and equipment under operating leases expiring at various dates through 2021 and 2024. On August 13, 2016, the Company entered into a 7 year operating lease for an office space located in San Francisco, CA. The Company also owns and operates a stand-alone Gamma Knife facility in Lima, Peru where it leases approximately 1,600 square feet for approximately $ 7,800 per month with a lease expiration date in January 2024. Future minimum payments under non-cancelable operating leases having initial terms of more than one year consisted of the following: Year ending December 31, 2021 $ 350,000 2022 355,000 2023 259,000 2024 8,000 $ 972,000 Payments for repair and maintenance agreements incorporated in operating lease agreements are not included in the future minimum operating lease payments shown above. Net rent expense was $ 404,000 and $ 380,000 for the years ended December 31, 2020 and 2019, respectively, and includes the above operating leases as well as month-to-month rental and certain executory costs. F- 32 Table of Contents A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 12 – C OMMITMENTS AND C ONTINGENCIES On December 20, 2018, the Company signed Second Amendments to two System Build Agreements for the Company’s second and third Mevion PBRT units. The Company and Mevion have agreed to upgrade the second and third PBRT units for which the Company has purchase commitments. The Company is actively seeking sites for these units but, to date, has not entered into agreements with any party for either placement of a PBRT unit or the related financing. The Company projects that it will be required to commence delivery of the second and third PBRT units no later than 2023. In the event the Company is unable to enter into customer agreements within the requisite time frame or receive an extension from Mevion, the Company could forfeit its deposits, which are described below. As of December 31, 2020, the Company had commitments to perform three ( 3 ) Cobalt-60 reloads and install four ( 4 ) Leksell Gamma Knife Icon Systems (“Icon”) at existing customer sites, and purchase two ( 2 ) Linear Accelerator ("LINAC") systems, one to be placed at an existing customer site and one at a new customer site. The Company also has a commitment to upgrade the Gamma Knife unit at its stand-alone facility in Ecuador to a Perfexion. The Cobalt-60 reloads, Icon upgrades, and LINAC purchases are scheduled to occur between 2021 and 2022. The Company expects to upgrade the equipment in Ecuador in the second quarter of 2021. Total Gamma Knife and LINAC commitments as of December 31, 2020 were $ 12,210,000 . There are no significant cash requirements, pending financing, for these commitments in the next 12 months. There can be no assurance that financing will be available for the Company’s current or future projects, or at terms that are acceptable to the Company. On July 21, 2017, the Company entered into a Maintenance and Support Agreement (the “Mevion Service Agreement”) with Mevion, which provides for maintenance and support of the Company’s PBRT unit at Orlando Health. The Mevion Service Agreement began September 5, 2017, was amended in 2018, and renews annually over a five ( 5 ) year period. The agreement requires an annual prepayment of $ 1,572,000 for the current contractual period. This payment portion was recorded as a prepaid contract and will be amortized over the one -year service period. As of December 31, 2020, the Company had commitments to service and maintain its Gamma Knife and PBRT equipment. The service commitments are carried out via contracts with Mevion, Elekta and Mobius Imaging, LLC. In addition, in April 2019, the Company signed agreements to service the Icon upgrades which will be installed at various dates between 2021 and 2022. The Company’s commitments to purchase two LINAC systems also include a 9 -year and 5 -year agreement to service the equipment, respectively. Total service commitments as of December 31, 2020 were $ 10,493,000 . The Gamma Knife and certain other service contracts are paid monthly, as service is performed. The Company believes that cash flow from cash on hand and operations will be sufficient to cover these payments. The Company estimates the following commitments for each of the equipment systems, with expected timing of payments as follows as of December 31, 2020: Total amounts committed 2021 2022-2023 2024-2025 After 5 years Long-term debt (includes interest) $ 5,251,000 $ 1,373,000 $ 1,854,000 $ 1,543,000 $ 481,000 Finance leases (includes interest) 9,771,000 6,590,000 2,659,000 522,000 — Future equipment purchases 46,210,000 2,175,000 44,035,000 — — Equipment service contracts 10,493,000 2,030,000 2,585,000 2,999,000 2,879,000 Acquisition working capital payments 197,000 197,000 — — — Operating leases 972,000 350,000 614,000 8,000 — Total Commitments $ 72,894,000 $ 12,715,000 $ 51,747,000 $ 5,072,000 $ 3,360,000 F- 33 A MERICAN S HARED H OSPITAL S ERVICES N OTES TO C ONSOLIDATED F INANCIAL S TATEMENTS N OTE 13 – R ELATED P ARTY T RANSACTIONS The Company’s Gamma Knife business is operated through its 81 % indirect interest in its GKF subsidiary. The remaining 19 % of GKF is owned by a wholly owned U.S. subsidiary of Elekta, which is the manufacturer of the Gamma Knife. Since the Company purchases its Gamma Knife units from Elekta, there are significant related party transactions with Elekta such as equipment purchases, commitments to purchase equipment, deposits for such equipment purchases, and costs to maintain the equipment. The Company believes that all its transactions with Elekta are arm’s-length transactions. At December 31, 2020, the Company had commitments to purchase three ( 3 ) Cobalt-60 reloads, one ( 1 ) Perfexion upgrade, and install four ( 4 ) Leksell Gamma Knife Icon Systems (“Icon”) and service the related equipment, as discussed in Note 12 – Commitments and Contingencies. F- 34