- $128$54Prescription eligible$138$33Prescription eligible
- $158$95$140Prescription eligible$605$217.80
- $108$98Prescription eligible$397Prescription eligible
- $215
- $213$511Prescription eligible
- $333$208$187
- $122$73.20Prescription eligible$122$73.20Prescription eligible$82$49.20Prescription eligible
- $82$49.20Prescription eligible$138$82.80Prescription eligible$48$28.80Prescription eligible
- $76$45.60Prescription eligible$84$45.60Prescription eligible$422$253.20Prescription eligible
- $242$145.20Prescription eligible$228$136.80Prescription eligible$399Prescription eligible
- $452Prescription eligible$427Prescription eligible$512$256Prescription eligible
- $286$137.40Prescription eligible$452$217.20Prescription eligible$424$229.20Prescription eligible







































































