I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Insurance is included.
12k for insurance is not enough.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels