- $418$200.40Prescription eligible$168$100.80Prescription eligible
- $138$74.40Prescription eligible$195$96$58Prescription eligible
- $205Prescription eligible$393Prescription eligible$194$105
- $698$418.80Prescription eligible$188$79.20Prescription eligible$176$105.60Prescription eligible
- $78Prescription eligible$425$229.80Prescription eligible$75$36
- $165$115.50$84$59Prescription eligible
- $118$39Prescription eligible$96Prescription eligible$74$39Prescription eligible
- $364$196.80Prescription eligible$406$219Prescription eligible
- $88$47.40$104Prescription eligible$168$80.40Prescription eligible
- $195$156$84Prescription eligible
- $109$76$108$58.20Prescription eligible$494$296.40Prescription eligible
- $174$104.40Prescription eligible$155$74.40Prescription eligible$124$59.40Prescription eligible







































































