$156$75Prescription eligible
- $163$88.20$517$248.40Prescription eligible
- $363Prescription eligible$310$148.80Prescription eligible$592$319.80Prescription eligible
- $225$121.80Prescription eligible$225$121.80Prescription eligible$630Prescription eligible
- $160$86.40$98$29Prescription eligible$184$66Prescription eligible
- $96$86Prescription eligible$96$86Prescription eligible$137$123Prescription eligible
- $254$137.40Prescription eligible$544$294Prescription eligible$393Prescription eligible
- $250Prescription eligible$434$234.60Prescription eligible$112$67.20Prescription eligible
- $234$126.60Prescription eligible$207Prescription eligible
- $137$73.80Prescription eligible$163$147Prescription eligible
- $106$95Prescription eligible$375Prescription eligible$363Prescription eligible
- $440$237.60Prescription eligible$195Prescription eligible$358$193.20Prescription eligible
- $202$109.20$674$364.20$404$193.80Prescription eligible







































































