$118$94Prescription eligible
$428$231Prescription eligible
$442$238.80Prescription eligible
$286Prescription eligible
$202Prescription eligible
$202Prescription eligible
$106Prescription eligible
$358$193.20Prescription eligible
$82$33Prescription eligible
$286Prescription eligible
$178Prescription eligible
$178Prescription eligible
$176Prescription eligible
$98$59Prescription eligible
$426$204.60Prescription eligible
$212Prescription eligible
$88$29Prescription eligible
$178$96Prescription eligible
$109$87Prescription eligible
$479$258.60Prescription eligible
$118$94Prescription eligible
$257Prescription eligible
$148$88.80Prescription eligible
$120$36Prescription eligible
$96$77Prescription eligible
$398$214.80Prescription eligible
$98$52.80Prescription eligible
$106$39Prescription eligible
$114Prescription eligible
$486$262.20Prescription eligible
$191Prescription eligible
$106$85Prescription eligible
$191Prescription eligible