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G. Medical Su lies and Ex enses Schedule <br />~1) <br /> <br />Item (2) <br />Total <br />Cost <br />N/A <br />Total -Medical Su lies and Ex ense <br /> <br />H. Cost of S ace -Non-Residential Schedule <br />~1~ <br /> <br />Item ~2) <br />Total <br />Cost <br />N/A <br />Total Cost of S ace -Non-Residential <br /> <br />I. Room and Board Costs -Residential Treatment <br />(1) <br /> <br />Item (2) <br /> <br />Method of Com utation (3) <br />Total <br />Cost <br />N/A <br />Total Room and Board Costs - Residential Treatment <br />