- $96Prescription eligible$82$39.60
- $128$115Prescription eligible$339Prescription eligible$178$85.20Prescription eligible
- $148$79.80Prescription eligible$582$314.40Prescription eligible$668$360.60Prescription eligible
- $554$299.40Prescription eligible$266$143.40Prescription eligible$104$39Prescription eligible
- $244$132$394$189Prescription eligible$254$137.40
- $196$117.60Prescription eligible$195$558$301.20Prescription eligible
- $134$72.60Prescription eligible$822$444$305$165Prescription eligible
- $151$81.60Prescription eligible$598$358.80Prescription eligible$262Prescription eligible
- $472$283.20Prescription eligible$342$205.20Prescription eligible$74$40.20
- $94$39Prescription eligible$246$118.20Prescription eligible$262Prescription eligible
- $124$67.20Prescription eligible$94$29Prescription eligible
- $218$104.40Prescription eligible$282$152.40$218







































































