- $174Prescription eligible
- $190Prescription eligible$352$189.60
- $128$54Prescription eligible
- $141$97Prescription eligible$143$33Prescription eligible$165$128
- $140Prescription eligible$452$245.40Prescription eligible$609$217.80
- $108$272Prescription eligible$397Prescription eligible
- $191Prescription eligible
- $215
- $333Prescription eligible
- $511Prescription eligible
- $128$79.20Prescription eligible$175$96Prescription eligible$202$118.80Prescription eligible
- $212$128.40Prescription eligible$184$100.20Prescription eligible$184$111.60Prescription eligible







































































