$78$39Prescription eligible
- $88$44Prescription eligible$94$47Prescription eligible
- $96$48Prescription eligible$120$48Prescription eligible$127$51Prescription eligible
- $88$53Prescription eligible$88$53Prescription eligible$108$54Prescription eligible
- $110$55$139$56Prescription eligible$96$58Prescription eligible
- $148$59Prescription eligible$108$65Prescription eligible$168$67Prescription eligible
- $172$69Prescription eligible$77$69$86$69Prescription eligible
- $86$69Prescription eligible$98$69Prescription eligible$94$75Prescription eligible
- $96$77Prescription eligible$86$77Prescription eligible$86$77Prescription eligible
- $86$77Prescription eligible$98$78Prescription eligible$114$80Prescription eligible
- $136$82Prescription eligible$117$82Prescription eligible$104$83Prescription eligible
- $118$83Prescription eligible$104$83Prescription eligible$208$83Prescription eligible
- $140$84Prescription eligible$86Prescription eligible$88Prescription eligible