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KlJ"lJ,"# <br />You,r Ho'r.a..e for tlea,Lth <br />KVH Workplace Health <br />General lnformation <br />Company Name Kittitas County Sheriff's Office <br />Physical Street Address 307 W. Umptanum Rd. <br />City, State, Zip Ellensburg, WA 98926 <br />Mailing Address (if different from physical) <br />Primary Contact Kim Dawson <br />Office Phone s09-962-7089 <br />Contact Email Kim.dawson @co. kittitas.wa. us <br />Office Fax: <br />Secondary Contact (if applicable) <br />Secondary Contact Phone <br />Guarantor lnformation <br />XCheck if the same as physicaladdress <br />Company Name <br />Street Address (Mailine) <br />City, State, Zip <br />Phone <br />Fax <br />Services Pricing <br />Physical Examination nstandard: S100 <br />Audiogram nstandard: $s5 <br />Venipuncture nstandard:5zz <br />Exec 1 Panel nstandard: $83 <br />Non-Federal Drug Screen, 5 panel nstandard: $+5 <br />EKG nstandard: S75 <br />U/A with micro nstandard:S2z <br />Stool Guaiac nstandard: $40 <br />Range of Motion nstandard: $+s <br />Spirometry nstandard: S60 <br />PA Chest X-Ray (1 view)nstandard: $100 <br />L Spine X-Ray nstandard: 560 <br />T Spine X-Ray nstandard: 560 <br />Optional Services <br />Hep B Titer nstandard: 560 <br />Hep B lnjections, each (series of 3)nstandard:SL03 <br />PSA (if medically indicated)nstandard:$t00 <br />Total w/o Optional Services Sttz