- $118$70.80Prescription eligible
- $118$63.60$128$115Prescription eligible
- $130$54.60Prescription eligible$258$154.80Prescription eligible
- $192Prescription eligible$492$265.80Prescription eligible$116$55.80Prescription eligible
- $582$314.40Prescription eligible
- $300Prescription eligible$118Prescription eligible$138$33Prescription eligible
- $908$490.20Prescription eligible$394$189Prescription eligible
- $688$371.40Prescription eligible$295Prescription eligible$154$83.40
- $518$310.80Prescription eligible$174$94.20$202$109.20
- $158$85.20$158$85.20$158$85.20
- $151$81.60Prescription eligible$118$56.40Prescription eligible$238$128.40Prescription eligible
- $214$193Prescription eligible$482$231.60Prescription eligible$86$41.40Prescription eligible







































































