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KYIJ,# <br />Youlr Llo'rfi,e for tle.a'Lth <br />KVH Workplace Health <br />Guarantor lnformation <br />XCheck if the same as physical address <br />Services Pricing <br />Physical Examination nstandard: $100 <br />Audiogram nstandard: $56 <br />Venipuncture nstandard:S22 <br />CM P14+LP+CBC/D/Plt+TSHw/rflx T4F nstandard: $83 <br />Non-Federal Drug Screen, 5 panel nstandard:$+s <br />EKG nstandard:$26 <br />U/A with micro nstandard: $27 <br />Stool Guaiac nstandard: $40 <br />Range of Motion nstandard:S45 <br />Spirometry nstandard: $25 <br />PA Chest X-Ray (L view)nstandard: $100 <br />L Spine X-Ray nstandard: $60 <br />T Spine X-Ray Estandard: 560 <br />Optional Services <br />Hep B Titer nstandard:560 <br />Hep B lnjections, each (series of 3)nstandard:$103 <br />PSA (if medically indicated)nstandard: $L00 <br />Total w/o Optional Services Sttz <br />Lab and MRO <br />LabCorp house account <br />Forms/ Reporting Results <br />Report results via email to Kim Dawson <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 509-962-7089 <br />Contact Email Kim.dawson @co. kittitas.wa. us <br />Office Fax: <br />Secondary Contact (if applicable): <br />Secondary Contact Phone