- $123$64.80Prescription eligible$106$29Prescription eligible
- $692$291Prescription eligible$191Prescription eligible$98$88Prescription eligible
- $75Prescription eligible$147$76.20Prescription eligible$106Prescription eligible
- $114$103Prescription eligible$393$275.10Prescription eligible$290$158.40Prescription eligible
- $269$213Prescription eligible$422Prescription eligible$178Prescription eligible
- $65Prescription eligible$114Prescription eligible$98Prescription eligible
- $138$64.20Prescription eligible$123$67.80Prescription eligible$248$197Prescription eligible
- $160Prescription eligible$114$103Prescription eligible$422Prescription eligible
- $129$52.80Prescription eligible

















































