@extends('Admin/layout/master') @section('title','User List') @section('content')
User List
{!! Form::open(['route' => 'hspcs.store', 'method' => 'post']) !!}
{!! Form::label('hcpsc_code', '2024 HCPCS Code', ['class' => 'form-label']) !!} {!! Form::text('hcpsc_code', null, ['class' => 'form-control', 'placeholder' => '2024 HCPCS Code']) !!} {!! $errors->first('hcpsc_code', ':message') !!}
{!! Form::label('short_description', 'Short Description', ['class' => 'form-label']) !!} {!! Form::text('short_description', null, ['class' => 'form-control', 'placeholder' => 'Short Description']) !!} {!! $errors->first('short_description', ':message') !!}
{!! Form::label('hcpcs_coverage_code', 'HCPCS Coverage Code', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_coverage_code', null, ['class' => 'form-control', 'placeholder' => 'HCPCS COVERAGE CODE']) !!} {!! $errors->first('hcpcs_coverage_code', ':message') !!}
{!! Form::label('hcpcs_action_code', 'HCPCS Action Code', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_action_code', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Action Code']) !!} {!! $errors->first('hcpcs_action_code', ':message') !!}
{!! Form::label('hcpcs_action_affective_date', 'HCPCS Action Effective Date', ['class' => 'form-label']) !!} {!! Form::date('hcpcs_action_affective_date', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Action Effective Date']) !!} {!! $errors->first('hcpcs_action_affective_date', ':message') !!}
{!! Form::label('hcpcs_code_added_date', 'HCPCS Code Added Date', ['class' => 'form-label']) !!} {!! Form::date('hcpcs_code_added_date', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Code Added Date']) !!} {!! $errors->first('hcpcs_code_added_date', ':message') !!}
{!! Form::label('hcpcs_multiple_pricing_indicated_code', 'HCPCS Multiple Pricing Indicator Code', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_multiple_pricing_indicated_code', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Multiple Pricing Indicator Code']) !!} {!! $errors->first('hcpcs_multiple_pricing_indicated_code', ':message') !!}
{!! Form::label('hcpcs_medicare', 'HCPCS Medicare Carriers Manual Reference Section Number', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_medicare', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Medicare Carriers Manual Reference Section Number']) !!} {!! $errors->first('hcpcs_medicare', ':message') !!}
{!! Form::label('hcpcs_type_service_code', 'HCPCS Type Of Service Code', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_type_service_code', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Type Of Service Code']) !!} {!! $errors->first('hcpcs_type_service_code', ':message') !!}
{!! Form::label('hcpcs_pricing_indicated_code', 'HCPCS Multiple Pricing Indicator Code ', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_pricing_indicated_code', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Multiple Pricing Indicator Code']) !!} {!! $errors->first('hcpcs_pricing_indicated_code', ':message') !!}
{!! Form::label('hcpcs_Anesthesia', 'HCPCS Anesthesia Base Unit Quantity', ['class' => 'form-label']) !!} {!! Form::text('hcpcs_Anesthesia', null, ['class' => 'form-control', 'placeholder' => 'HCPCS Anesthesia Base Unit Quantity']) !!} {!! $errors->first('hcpcs_Anesthesia', ':message') !!}
{!! Form::label('long_description', 'Long Description', ['class' => 'form-label']) !!} {!! Form::textarea('long_description', null, ['class' => 'form-control', 'placeholder' => 'Long Description','rows'=> 3]) !!} {!! $errors->first('long_description', ':message') !!}
{!! Form::submit('Add', ['class' => 'btn btn-primary btn-sm my-2']) !!} Back
{!! Form::close() !!}
@endsection