$168$90.60
- $478$258Prescription eligible$166$99.60Prescription eligible
- $120$64.80$300$144Prescription eligible$470$253.80Prescription eligible
- $316$151.80$618$296.40Prescription eligible$434$234.60Prescription eligible
- $220Prescription eligible$247$74.40Prescription eligible$106$95Prescription eligible
- $188$101.40Prescription eligible$104$94Prescription eligible
- $272$147$218$117.60Prescription eligible
- $495Prescription eligible$108$100$54
- $416$174.60Prescription eligible$425$178.80Prescription eligible$668$320.40Prescription eligible
- $168$90.60
- $395Prescription eligible$138$82.80Prescription eligible$338$162







































































