$88$53
- $94$56Prescription eligible$88$62Prescription eligible
- $166$66Prescription eligible$98$69Prescription eligible$140$70Prescription eligible
- $122$73Prescription eligible$75Prescription eligible$94$75Prescription eligible
- $76Prescription eligible$78Prescription eligible$98$78Prescription eligible
- $114$80Prescription eligible$116$81Prescription eligible
- $138$83Prescription eligible$104$83Prescription eligible$106$85Prescription eligible
- $108$86Prescription eligible$88Prescription eligible$99$89
- $89Prescription eligible$114$91Prescription eligible$184$92Prescription eligible
- $116$93Prescription eligible$134$94Prescription eligible$106$95Prescription eligible
- $138$97$108$97$108$97
- $108$97$124$99Prescription eligible$142$99Prescription eligible
- $124$99Prescription eligible$112$101Prescription eligible$132$106