$191Prescription eligible
$114Prescription eligible
$207Prescription eligible
$277$133.20Prescription eligible
$106Prescription eligible
$280$151.20Prescription eligible
$106Prescription eligible
$178Prescription eligible
$212Prescription eligible
$191Prescription eligible
$108$86Prescription eligible
$128$76.80Prescription eligible
$244$132Prescription eligible
$106$85Prescription eligible
$194Prescription eligible
$198$106.80Prescription eligible
$98$46.80Prescription eligible
$254$137.40Prescription eligible
$314$150.60Prescription eligible
$220Prescription eligible