- $140Prescription eligible$605$217.80
- $471$226.20$244$132
- $394$189Prescription eligible$254$137.40
- $207$239$178Prescription eligible
- $94$51$498$268.80Prescription eligible$222Prescription eligible
- $422Prescription eligible$194Prescription eligible$178Prescription eligible
- $191Prescription eligible$258$154.80Prescription eligible$466$251.40Prescription eligible
- $346$186.60Prescription eligible$395Prescription eligible
- $440Prescription eligible$207Prescription eligible$207Prescription eligible
- $109$58.80Prescription eligible$114$91Prescription eligible$191Prescription eligible
- $567$238.20Prescription eligible$217Prescription eligible$588$317.40Prescription eligible
- $648$518Prescription eligible$472$255Prescription eligible$185$100.20







































































