- $277$116.40
- $239$183$99$82$44.40
- $335$160.80$215$103.20
- $479$258.60Prescription eligible$304$582$349.20
- $427$244Prescription eligible$231
- $457Prescription eligible
- $457
- $199$107.40Prescription eligible$82$44.40
- $83$45$78$42$108$64.80Prescription eligible
- $164$88.80Prescription eligible$206$111Prescription eligible$174$104.40Prescription eligible
- $224$202Prescription eligible$106$57Prescription eligible$85Prescription eligible









































































