- $165$132$104Prescription eligible
- $106$95Prescription eligible$397Prescription eligible
- $436$209.40Prescription eligible
- $113$54Prescription eligible$259$124.20Prescription eligible$262$236Prescription eligible
- $259$207Prescription eligible$155Prescription eligible$239$114.60Prescription eligible
- $378$204Prescription eligible$134$72.60Prescription eligible$115$104Prescription eligible
- $221$119.40Prescription eligible$86Prescription eligible$98$88Prescription eligible
- $218Prescription eligible$397$214.20Prescription eligible
- $110$59.40Prescription eligible$96Prescription eligible$94$29Prescription eligible
- $88$29Prescription eligible$98$88Prescription eligible
- $295$124.20Prescription eligible







































































