$248$133.80
- $578$312Prescription eligible$176$105.60Prescription eligible
- $588$352.80Prescription eligible$114$103Prescription eligible$648$310.80Prescription eligible
- $108$97Prescription eligible$478$258Prescription eligible$185$100.20
- $185$100.20$185$100.20$228$123
- $822$444$163$78$163$88.20Prescription eligible
- $163$78$163$88.20$163$88.20
- $267$128.40Prescription eligible$109$58.80Prescription eligible$106$95Prescription eligible
- $108$64.80Prescription eligible$308$147.60Prescription eligible$226$121.80Prescription eligible
- $95Prescription eligible$478$258Prescription eligible$246$132.60Prescription eligible
- $256$138Prescription eligible$267$128.40Prescription eligible$246$118.20Prescription eligible
- $178Prescription eligible$766$367.80Prescription eligible$113$61.20Prescription eligible
- $218$91.80Prescription eligible$168$80.40$220Prescription eligible







































































