- $188$101.40Prescription eligible$152$82.20Prescription eligible$152$82.20Prescription eligible
- $209$87.60Prescription eligible$204$97.80Prescription eligible$124$74.40Prescription eligible
- $141$59.40Prescription eligible$108$64.80Prescription eligible$108$64.80Prescription eligible
- $113$67.80Prescription eligible$108$64.80Prescription eligible$108$45.60Prescription eligible
- $118$70.80Prescription eligible$108$64.80Prescription eligible





























