- $578$277.20Prescription eligible
- $196Prescription eligible$160Prescription eligible$148$70.80Prescription eligible
- $162$78Prescription eligible$258$154.80Prescription eligible$416$199.80Prescription eligible
- $582$314.40Prescription eligible$124$67.20Prescription eligible$363Prescription eligible
- $268$144.60Prescription eligible$108$51.60Prescription eligible$106$51Prescription eligible
- $154$83.40Prescription eligible$766$367.80Prescription eligible$108$64.80Prescription eligible
- $104$29Prescription eligible$217$116$62.40
- $78Prescription eligible$288$155.40Prescription eligible
- $254$106.80Prescription eligible
- $248$133.80Prescription eligible
- $148$79.80Prescription eligible$106Prescription eligible$393Prescription eligible
- $145$78.60Prescription eligible$299$90







































































