$126$63
- $292$157.80
- $137$123Prescription eligible
- $178$160$108
- $395Prescription eligible$338$162
- $96$86Prescription eligible
- $163$130Prescription eligible$178$252$136.20Prescription eligible
- $128$54Prescription eligible$154$139Prescription eligible
- $139$111$117$59$109$55
- $123$62$68$86$41.40
- $287$154.80$188$90$180







































































