- $164$98.40Prescription eligible$167$100.20Prescription eligible$182$109.20Prescription eligible
- $168$100.80Prescription eligible$324$194.40Prescription eligible$139$83.40Prescription eligible
- $132$63.60$368$198.60Prescription eligible$188$112.80Prescription eligible
- $336$181.20Prescription eligible$316$151.80























