$191Prescription eligible
$114Prescription eligible
$207Prescription eligible
$277$133.20Prescription eligible
$106Prescription eligible
$280$151.20Prescription eligible
$106Prescription eligible
$178Prescription eligible
$212Prescription eligible
$398$214.80Prescription eligible
$202Prescription eligible
$191Prescription eligible
$202Prescription eligible
$108$86Prescription eligible
$128$61.20Prescription eligible
$636$381.60Prescription eligible
$222$133.20Prescription eligible
$200$120Prescription eligible
$106Prescription eligible
$261Prescription eligible
$194Prescription eligible
$98$58.80Prescription eligible
$254$137.40Prescription eligible
$304$164.40Prescription eligible