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ProCare Work Injury Center <br />Pricing Sheet for Medical Services <br />Exhibit A <br />City of Santa Ana Non -Industrial Medical Services <br />Physicals: <br />Basic Employer Physical (includes UA dip, distance vision, basic color vision): <br />Basic Physical: $85 <br />UA:$10 <br />Titmus (color, depth, periphery): S40 of Snellen eye chart $10 <br />Total: $135 or $105 with Snellen instead of Titmus vision exam <br />Annual Employer Physical (includes UA dip, distance vision, basic color vision) <br />Total: $135 or $105 with Snellen instead of Titmus vision exam <br />Pre -Employment Physical (includes UA dip, distance vision, basic color vision) <br />Total: $135 or $105 with Snellen instead of Titmus vision exam <br />Fit For Duty/Return toWork (MUSThave Copy ofjob descnptlon) : <br />Basic Fit For Duty (review of prior medical history, exam and review of job duties) : $250 <br />Complex Fit For Duty (review of prior complex medical history, exam and review of job duties): <br />$500 <br />Commercial Driver Exams: $105 <br />Respiratory Fit Testing: <br />Respiratory Evaluation (includes: Mask Fit Test, OSI IA questionnaire review, PFT): <br />PFT: $45 <br />OSHA Q,: $30 <br />Mask Fit Test: $65 <br />Total: $140 <br />PFT: $45 <br />OSHA Questionnaire Review: $30 <br />Mask Fit Test: $65 <br />Drug Screens: <br />Breath Alcohol Test: $55 (with confirmation) <br />5 Panel Rapid: $40 <br />10 panel Rapid: $40 <br />9 Panel Non -Dot p1793N: $45 <br />10 Panel Non -Dot 46633N: $45 <br />DOT Drug Screen: $55 <br />MRO Interpretation of Positive Drug Screen: $TAt'EVIEWED & APPROVED <br />By Risk MANAGEMENT DiV1SiON <br />AP 9 2020 <br />ANC{iE ACEVEdo <br />