$88$53
- $94$56Prescription eligible$86$60Prescription eligible
- $78$62Prescription eligible$166$66Prescription eligible$140$70Prescription eligible
- $94$75Prescription eligible$76Prescription eligible$86$77Prescription eligible
- $98$78Prescription eligible$98$78Prescription eligible$88$79Prescription eligible
- $114$80Prescription eligible$116$81Prescription eligible$118$83Prescription eligible
- $104$83Prescription eligible$106$85Prescription eligible$106$85Prescription eligible
- $108$86Prescription eligible$108$86Prescription eligible$107$86Prescription eligible
- $88Prescription eligible$99$89$89Prescription eligible
- $128$90Prescription eligible$114$91Prescription eligible$114$91Prescription eligible
- $116$93Prescription eligible$134$94Prescription eligible$138$97
- $138$97Prescription eligible$108$97$108$97
- $108$97Prescription eligible$108$97$124$99Prescription eligible