$119$64.20
- $208$124.80Prescription eligible$134$64.20Prescription eligible
- $129$54Prescription eligible$170Prescription eligible$138$74.40Prescription eligible
- $248$133.80Prescription eligible$156$75Prescription eligible$488$263.40Prescription eligible
- $258$123.60Prescription eligible$648$310.80Prescription eligible$114$103Prescription eligible
- $219$118.20Prescription eligible$166$89.40Prescription eligible$238$128.40Prescription eligible
- $270$97.20Prescription eligible$228$182Prescription eligible$205$143.50
- $194$105$185$100.20$185$100.20
- $185$100.20$89$48Prescription eligible$211$101.40
- $202$121.20$228$123$181$87
- $668$360.60$668$360.60$163$78Prescription eligible
- $163$88.20Prescription eligible$158$85.20$137$57.60Prescription eligible
- $145$78.60Prescription eligible$145$78.60Prescription eligible$663$358.20Prescription eligible







































































