- $272$163.20
- $186Prescription eligible$587$211.20
- $76Prescription eligible$165$115.50
- $363$159$76.20$122$73.20Prescription eligible
- $82$49.20Prescription eligible$82$49.20Prescription eligible$138$82.80Prescription eligible
- $48$28.80Prescription eligible$84$45.60Prescription eligible$246$132.60Prescription eligible
- $512$256Prescription eligible$114$91Prescription eligible$114$91Prescription eligible
- $176$84.60Prescription eligible$302$145.20Prescription eligible$262$236Prescription eligible
- $339Prescription eligible$150Prescription eligible$192Prescription eligible
- $422Prescription eligible$582$314.40Prescription eligible$328$196.80Prescription eligible
- $496$297.60Prescription eligible$606$327Prescription eligible$375Prescription eligible
- $198$83.40$213







































































