- $246$197Prescription eligible$563$304.20Prescription eligible
- $248$133.80Prescription eligible$219$118.20Prescription eligible$79$47.40Prescription eligible
- $182$98.40Prescription eligible$220Prescription eligible$412$172.80Prescription eligible
- $346$186.60Prescription eligible$141$59.40Prescription eligible$65Prescription eligible
- $185$100.20$163$78Prescription eligible$262$141.60
- $201Prescription eligible$266$213Prescription eligible$200$108Prescription eligible
- $363Prescription eligible$267$144Prescription eligible$126$67.80Prescription eligible
- $191Prescription eligible$533$288Prescription eligible$200$96Prescription eligible
- $121$51Prescription eligible$188$101.40Prescription eligible$85Prescription eligible
- $642$308.40Prescription eligible$88Prescription eligible$163$88.20Prescription eligible
- $107$64.20Prescription eligible$478$258Prescription eligible$219$118.20Prescription eligible
- $201Prescription eligible$201Prescription eligible$219$105Prescription eligible







































































