$163$130Prescription eligible
- $137$123Prescription eligible
- $176$105.60Prescription eligible$217
- $162$67.80Prescription eligible$368$198.60Prescription eligible
- $154$139Prescription eligible
- $209$100.20Prescription eligible$287$154.80
- $153$64.20Prescription eligible$188$90$330$158.40Prescription eligible
- $145$61.20Prescription eligible$288$121.20$139$58.20Prescription eligible
- $309$148.20$113$47.40Prescription eligible$139$75








































































