- $118$63.60
- $128$115Prescription eligible$257$138.60
- $271$135.50$138$82.80Prescription eligible$48$28.80Prescription eligible
- $84$45.60Prescription eligible$452Prescription eligible$578$277.20Prescription eligible
- $196Prescription eligible$162$78Prescription eligible$304$145.80Prescription eligible
- $492$265.80Prescription eligible$136$65.40Prescription eligible$418$225.60Prescription eligible
- $346$186.60Prescription eligible$254$137.40
- $204$110.40$106$39Prescription eligible
- $195
- $348$208.80Prescription eligible$238$128.40Prescription eligible
- $258$139.20Prescription eligible$166$99.60Prescription eligible$89$48Prescription eligible







































































