- $158$85.20Prescription eligible
- $193$104.40$309Prescription eligible$128$115Prescription eligible
- $254$106.80Prescription eligible$268$144.60Prescription eligible$148$62.40Prescription eligible
- $495Prescription eligible$294$176.40Prescription eligible$76Prescription eligible
- $244$132Prescription eligible$165$115.50
- $130$54.60Prescription eligible$82$49.20Prescription eligible$76$45.60Prescription eligible
- $84$45.60Prescription eligible$427Prescription eligible$174$83.40Prescription eligible
- $158$75.60Prescription eligible$222Prescription eligible$226$181Prescription eligible
- $452Prescription eligible$393Prescription eligible$422Prescription eligible
- $363Prescription eligible$268$144.60Prescription eligible$148$88.80Prescription eligible
- $194Prescription eligible$248$118.80Prescription eligible$268$128.40Prescription eligible
- $582$314.40Prescription eligible$96$77Prescription eligible







































































