@extends('Admin/layout/master')
@section('title','Add HCPCS')
@section('content')
    <div class="content-wrapper">
        <!-- Content -->

        <div class="container-xxl flex-grow-1 container-p-y">
            <div class="row">
                <div class="col-md-12">
                    <div class="card mb-4">
                        <h5 class="card-header">Add HCPCS</h5>
                        {!! Form::open(['route' => 'hspcs.store', 'method' => 'post']) !!}
                        <div class="card-body">
                            <div class="row">
                                <div class="col-6">
                                    <div>
                                        {!! 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', '<span class="text-danger">:message</span>') !!}
                                    </div>
                                </div>
                                <div class="col-6">
                                    <div>
                                        {!! Form::label('short_description', 'Short Description', ['class' => 'form-label']) !!}
                                        {!! Form::text('short_description', null, ['class' => 'form-control', 'placeholder' => 'Short Description']) !!}
                                        {!! $errors->first('short_description', '<span class="text-danger">:message</span>') !!}
                                    </div>
                                </div>

                                <div class="col-6">
                                    <div>
                                        {!! 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', '<span class="text-danger">:message</span>') !!}
                                    </div>
                                </div>
                                <div class="col-6">
                                    <div>
                                        {!! 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', '<span class="text-danger">:message</span>') !!}
                                    </div>
                                </div>

                                <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-6">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            <div class="col-12">
                                <div>
                                    {!! 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', '<span class="text-danger">:message</span>') !!}
                                </div>
                            </div>
                            </div>
                            {!! Form::submit('Add', ['class' => 'btn btn-primary btn-sm my-2']) !!}
                            <a href="{{ route('hspcs.index') }}" class="btn btn-info btn-sm">Back</a>
                        </div>
                        {!! Form::close() !!}
                    </div>
                </div>
            </div>
        </div>
        <div class="content-backdrop fade"></div>
    </div>
@endsection