$132$63.60
- $168$80.40$74$40.20Prescription eligible
- $116$62.40$134$48Prescription eligible$164$98.40Prescription eligible
- $144$78Prescription eligible$428$205.20Prescription eligible$204$97.80Prescription eligible
- $328$138Prescription eligible$259$108.60Prescription eligible$168$80.40
- $178$64.20$152$73.20Prescription eligible$132$71.40
- $91$38.40$335$141$262Prescription eligible
- $404$193.80
- $168$50.40Prescription eligible$246$103.20Prescription eligible
- $247$74.40Prescription eligible$104$94Prescription eligible$393Prescription eligible
- $218$117.60$231$448$214.80Prescription eligible







































































