A hospital room with a patient using a medical device to administer insulin.
This includes the company's quarterly report on Form 10-Q for the three month period ended March 31 and June 30, 2023, the annual report on Form 10-K for the year ended December 31, 2022, and the definitive proxy statement for the Annual Meeting of Shareholders that was held on June 20, 2023. The company assumes no obligation to update the information contained in this conference call. Before I turn the call over to Ray, I'd like to announce that we're instituting a new Q&A policy with this quarter's call. We're going to ask everybody to limit their questions to one question and one follow-up. As always, we'll be happy to take additional questions offline at any time. With that, I'd now like to turn the call over to Ray Stachowiak, Executive Chairman.
This included a net interest expense of $128,000, down significantly from last year and increasingly offset by interest income on our growing cash balances. We've also engaged the services of a compensation consulting firm to review our compensation practices. At quarter end, our cash balances totaled $14.7 million or approximately $229 per share. AMS consistently generates positive cash flow even throughout the pandemic. During the quarter, our sales and marketing team continued to generate and work on many new business opportunities. We're especially excited by three unique opportunities, which we first mentioned on our last call. In the third quarter, we invested approximately $320,000, advancing these unique opportunities. Without these expenses, net income would have been approximately $240,000 higher.
In addition, in the second quarter, we invested roughly $250,000 on these projects. Together, this totals $570,000 that we've invested so far this year. We look forward to announcing more details about these unique projects that will expand our domestic footprint at the appropriate time. Internationally, the installation of new equipment with expanded treatment offerings at two of our locations has progressed well. At our newest Cancer Center joint venture in Puebla, Mexico, installation of the digital linear accelerator with VMAT, IGRT and radiosurgerbility for Linac is well underway. This will be a new revenue stream for us when patient treatments start up in early 2024, and it will be the most advanced radiation therapy treatment system within our catchment area.
At our center in Ecuador, installation of the upgraded Gamma Knife ICON is complete and patient treatments are expected to restart this month. This will be the only Gamma Knife in Ecuador for non-invasive radio surgery. I'm proud to say that AMS will have the most advanced radiation cancer treatment system in their region when the installations are complete. Cancer patients in those areas are in need of these advanced treatments, and we look forward to serving them. In closing, I hope I've conveyed some of the excitement that we all feel here at AMS. I wish I could share more details, so it will be clearer to you what we're working on. I can't tell you this, we expect a unique return from the $570,000 that we've invested. The management team and the Board all take our fiduciary responsibility to deliver the highest returns very seriously, and we're constantly weighing the expected returns of investment opportunities against other uses of our cash.
That's our job. I'm very comfortable with the decisions we've made and the potential of the opportunities we're working on. With that, I'll turn the call over to Peter. Peter?
Peter Gaccione: Thank you, Ray, and good afternoon, everyone. During the third quarter, the sales pipeline continued to grow. We attribute this growth to our sales team, which has hit its stride and our expanded financial solutions and closer integration with our strategic OEMs on targeted prospects. As Ray talked about, we have several key projects that are processing through the necessary sales cycle that we look forward to announcing at the appropriate time. In addition, in the third quarter, we signed two new lease extensions with existing customers, which are our third and fourth new orders this year. These both include equipment upgrades to the Leksell Gamma Knife Espirit, the latest model, and they will be among the first 10 in the U.S. when these installations are completed early in Q1.
We're working on several other opportunities for new business, as well as with existing customers for ongoing agreement extensions and product upgrades to newer cancer treatment technology as well. Also during the third quarter, for the first time, AMS was an exhibitor at the annual ASTRO known as the American Society of Radiation Therapy and Oncology Conference, the largest radiation oncology society in the world. The booth was fully staffed with our team, and it was a great opportunity for us to meet with customers, partners and OEMs. At the conference, we advanced several new business opportunities and added to the breadth and depth of our relationships. We've also been in attendance at other trade shows this year, such as the American Association of Neurosurgical Society, known as the AA&S, the Congress of Neurological Surgeons known as the CNS, the Proton Therapy Cooperative Group, PTCOG and the Peru Radiotherapy Congress.
We also attended three conferences in Ecuador this year, where we've developed great referral sources. These include the seventh Congress of International neurology, which we did in March, the Women in dentistry conference in May and the Expo Dental Conference in September. Recently, we launched a new dedicated website for GKF, AMS' financing subsidiary. This new site offers neuroscience and radiosurgery professionals access to creative financing alternatives to obtain a new Gamma Knife Espirit and other services. Our in-house customer advocate has been a great addition. Not only has he helped secure the three agreement extensions with existing customers that we've announced this year. He has also continued to help improve the activity levels on our Gamma Knife sites.
In the third quarter, Gamma Knife procedures increased approximately 8% period-over-period after improving the utilization in the second quarter as well. In closing, we've built good momentum both internationally and in the U.S., and AMS has a full pipeline of opportunities and is supported by a strong financial position. I will now turn the call over to Bob for a financial overview.
Robert Hiatt: Thank you, Peter, and good afternoon, everyone. Third quarter revenue increased 6.3% to $5.1 million compared to $4.8 million in the year ago period. Domestic revenue was $4.1 million, an increase of 1.1% and international revenue was $1 million compared to $727,000 a year ago, an increase of 35.9%. Third quarter revenue for the proton therapy system in Florida was $2.2 million, a decrease of 5.9% primarily due to a decrease in fractions, offset by continued increases in average reimbursement. Total proton therapy fractions in the third quarter were 1,188, a decrease of 12.8% or 175 fractions. This is within the typical quarterly fluctuation range. Total Gamma Knife revenue increased 9.9% to $2.7 million. The increase in overall Gamma Knife revenue was due to an increase in procedures combined with a modest increase in average reimbursement.
Total Gamma Knife procedures were 316 for the third quarter, compared to 293 in the third quarter a year ago, an increase of 7.8% or 23 procedures, which is also within the range of typical quarterly fluctuations. Gross margin for the third quarter of 2023 increased 7.4% to $2.1 million or 40.9% of revenue compared to gross margin of $2 million or 40.5% of revenue for the third quarter last year. Selling and administrative costs increased 37.7% to $1.7 million for the third quarter of 2023 compared to $1.3 million in the year ago quarter. This includes approximately $320,000 that we've invested in pursuing new business opportunities, as Ray talked about, as well as higher sales and marketing expenses. Net interest expense was $128,000 in the 2023 period compared to $216,000 in the third quarter of last year.
The decrease is due to an increase in the interest rate on the company's variable rate debt, offset by increases in interest income on the company's growing cash balance. Operating income for the third quarter of 2023 was $90,000 compared to operating income of $448,000 in the third quarter of 2022, which reflects the higher selling and administrative and interest expenses. We recorded an income tax expense of $60,000 for the third quarter compared to $176,000 for the same period last year. The decrease was primarily due to lower earnings, return to provision adjustments arising from foreign tax returns and permanent domestic tax differences. Net income attributable to American Shared Hospital Services in the third quarter of 2023 was $118,000 or $0.02 per diluted share compared to net income of $316,000 or $0.05 per diluted share for the third quarter of 2022.
The decrease was primarily due to higher interest expense and higher selling and administrative expense in support of the company's new business opportunities. As Ray said, we invested approximately $320,000 in the third quarter, advancing new business opportunities. Without these expenses, net income would have been approximately $240,000 higher. Fully diluted weighted average common shares outstanding were $6.4 million and $6.3 million for the third quarter of 2023 and 2022, respectively. Adjusted EBITDA, a non-GAAP financial measure was $1.7 million in the current period compared to $2 million for the third quarter of 2022. At September 30, 2023, cash, cash equivalents and restricted cash was $14.7 million compared to $12.5 million at December 31, 2022.
Shareholders' equity, excluding non-controlling interest in subsidiaries was $22.1 million or $3.33 per outstanding share at quarter end, compared to $21.6 million or $3.30 per outstanding share at December 31, 2022. This concludes the formal part of our presentation. Thank you for joining us today. We look forward to updating you on our progress in the quarters ahead Jason, we'd now like to turn the call back to you and open it up for questions.
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