- $258$154.80Prescription eligible$207Prescription eligible
- $191Prescription eligible$158$75.60Prescription eligible$158$75.60Prescription eligible
- $98$69Prescription eligible$427$393$275.10Prescription eligible
- $249Prescription eligible$106Prescription eligible$106$39Prescription eligible
- $106$85Prescription eligible$191Prescription eligible$244Prescription eligible
- $178$139$97Prescription eligible
- $262$141.60Prescription eligible$248Prescription eligible
- $109$58.80Prescription eligible$160Prescription eligible















































