$298$160.80Prescription eligible
- $210$100.80Prescription eligible$277$133.20Prescription eligible
- $432$207.60Prescription eligible$238$128.40Prescription eligible$78$42Prescription eligible
- $496$238.20$280$151.20Prescription eligible$86$60Prescription eligible
- $140$75.60Prescription eligible$326$156.60Prescription eligible$164$88.80Prescription eligible
- $115$58Prescription eligible$418$225.60$118$63.60
- $88$26.40Prescription eligible$587$246.60$266$143.40Prescription eligible
- $134$64.20$115$58Prescription eligible$98$52.80Prescription eligible
- $97$58Prescription eligible$442$212.40Prescription eligible$358$193.20Prescription eligible
- $82$33Prescription eligible$118$63.60$118$56.40Prescription eligible
- $139$75$208$112.20Prescription eligible$138$74.40Prescription eligible
- $348$166.80$120$36Prescription eligible$118$63.60Prescription eligible
- $428$231Prescription eligible$128$61.20Prescription eligible$164$88.80Prescription eligible