@extends('layouts.medflixtemplate')
{{--    --}}
@section('head')

    <link href="https://cdn.jsdelivr.net/npm/select2@4.0.13/dist/css/select2.min.css" rel="stylesheet" />
    <script src="https://cdn.jsdelivr.net/npm/select2@4.0.13/dist/js/select2.min.js"></script>
    <style>
        #service-select{
            color: inherit;
            font: inherit;
        }

        #service-code{
            width: 120px;
            color: inherit;
            font: inherit;
        }
    </style>

@endsection
{{--    --}}
@section('content')
<div class="card">

    <div class="card-header">
        <h3>Añadir Ticket</h3>
        {{-- Banner For Email On Database::START --}}
        @if($errors->any())
            <div class="alert alert-danger alert-block">
                <strong><center>{{ $errors }}</center></strong>
            </div>
        @endif
        {{-- Banner For Email On Database::END --}}
    </div>

    <div class="card-body">
    <br>
        <form method="post" action="{{ url('tickets/') }}" enctype="multipart/form-data">
        {{ csrf_field() }}
            <div class="container">
                <div class="form-row">
                    <div class="form-group col-md-3">
                        <input type="text" class="form-control" id="inputEmail4" placeholder="Nombre" name="first_name" value="{{ old('first_name') }}">
                    </div>
                    <div class="form-group col-md-3">
                        <input type="text" class="form-control" id="inputPassword4" placeholder="Apellido Paterno" name="last_name" value="{{ old('last_name') }}">
                    </div>
                    <div class="form-group col-md-3">
                        <input type="text" class="form-control" id="inputPassword4" placeholder="Apellido Materno" name="maternal_lastname" value="{{ old('maternal_lastname') }}">
                    </div>
                </div>
                <div class="form-row">
                    <div class="form-group col-md-2">
                        <label for="inputState">Fecha de Nacimiento</label>
                        <input name="birthdate" type="date" class="form-control" id="inputCity" value="{{ old('birthdate') }}">
                    </div>
                    <div class="form-group col-md-1">
                        <label for="inputState">Sexo</label>
                        <select id="inputState" class="form-control" type="text" name="sex" required>
                            <option selected>{{ old('sex') }}</option>
                            <option value="F">F</option>
                            <option value="M">M</option>
                        </select>
                    </div>
                </div>

                <div class="form-row">
                    <div class="form-group col-md-3">
                        <input name="email" type="email" class="form-control" id="inputCity" placeholder="Email" value="{{ old('email') }}">
                    </div>
                    <div class="form-group col-md-3">
                        <input name="phone" type="text" class="form-control" id="inputPassword4" placeholder="Telefono" value="{{ old('phone') }}">
                    </div>
                    <div class="form-group col-md-3">
                        <input name="alt_phone" type="text" class="form-control" id="inputPassword4" placeholder="Telefono Alterno" value="{{ old('alt_phone') }}">
                    </div>
                </div>
                <h3>Necesitamos su identificacion</h3>
                <div class="form-row">
                    <div class="custom-file col-md-3">
                        <input name="identification" type="file" class="form-control-file" id="customFile" value="{{ old('identification') }}">
                        <br>
                            <label class="" for="customFile">ID</label>
                    </div>
                </div>
                <br>
                <hr>
                <br>

                <h3>Plan Medico Primario</h3>
                <div class="form-row">
                    <div class="form-group col-my-3">
                        <select class="custom-select mr-sm medplan" type="text" name="plan_name" required>
                            <option selected>
                                @if(old('plan_name') == null)
                                    Plan Medico
                                @else
                                    {{ old('plan_name') }}
                                @endif
                            </option>
                            @foreach ($md_list as $md)
                            <option value="{{$md->md_name}}">{{ $md->md_name }}</option>
                            @endforeach
                        </select>
                    </div>
                    <div class="form-group col-md-3">
                        <input name="insured_name" type="text" class="form-control" id="inputPassword4" placeholder="Nombre Del Asegurado" hidden>
                    </div>
                </div>

                <div class="form-row">
                    <div class="form-group col-md-3">
                        <input name="insured_number" id="mp-id" type="text" class="form-control mp-id" placeholder="Numero Del Asegurado" required value="{{ old('insured_number') }}">
                    </div>
                    <div class="form-group col-md-3">
                        <input name="group_number" type="text" class="form-control mp-group" placeholder="Numero De Grupo" hidden>
                    </div>
                    <div class="custom-file col-md-3">
                        <input name="card_img" type="file" class="form-control-file" id="customFile" value="{{ old('card_img') }}">
                        <br>
                        <label class="" for="customFile">Foto Plan Medico Primario</label>
                        {{--  label class="custom-file-label"  --}}
                    </div>
                </div>
                <div class="col-8">
                    <div class="custom-control custom-checkbox custom-control-inline">
                        <input name="aplica" type="checkbox" class="form-check-input checkbox" id="checkboxid" value="0" onclick="checkaplica()">
                        <label>Tengo Plan Medico Secundario</label>
                    </div>
                </div>
        {{-- Seccion : Plan Medico Secudario --}}
                <h3 class="aplica" hidden>Plan Medico Secundario</h3>
                <div class="form-row">
                    <div class="form-group col-my-3">
                        <select type="text" name="plan_name2nd" class="custom-select mr-sm aplica medplan2" disabled hidden>
                            <option selected class="aplica" disabled>Plan Medico</option>
                            @foreach ($md_list as $md)
                            <option value="{{$md->md_name}}">{{ $md->md_name }}</option>
                            @endforeach
                        </select>
                    </div>
                    <div class="form-group col-md-3">
                        {{--  <input name="insured_name2nd" type="text" class="form-control aplica" placeholder="Nombre del asegurado" disabled hidden>  --}}
                    </div>
                </div>
                <div class="form-row">
                    <div class="form-group col-md-3">
                        <input name="insured_number2nd" type="text" class="form-control aplica mp-id2" placeholder="Numero del asegurado" disabled hidden>
                    </div>
                    <div class="form-group col-md-3">
                        {{--  <input name="group_number2nd" type="text" class="form-control aplica mp-group2" placeholder="Numero de grupo" disabled hidden>  --}}
                    </div>
                    <div class="custom-file col-md-3">
                        <input name="card_img2nd" type="file" class="custom-file-input aplica" id="inputGroupFile01" disabled hidden>
                        <label class="custom-file-label aplica" for="inputGroupFile01" disabled hidden>Foto Plan Medico Secundario</label>
                    </div>
                </div>
                <hr>
                <h3>Servicios</h3>
                <div class="form-row">
                    <div class="form-group col-md-4">
                        <select name="service" class="custom-select" id="service-select" type="text" name="service">
                            <option selected>
                                @if(old('service') == null)
                                    Servicio que solicita
                                @else
                                    {{ old('service') }}
                                @endif
                            </option>
                            {{-- <option value="MRI">MRI</option>
                            <option value="MRA">MRA</option>
                            <option value="Dual Sorce CT">Dual Sorce CT</option>
                            <option value="CTA">CTA</option>
                            <option value="Nuclear Medicine">Nuclear Medicine</option>
                            <option value="SPECT-CT">SPECT-CT</option>
                            <option value="PET-CT">PET-CT</option>
                            <option value="DEXA-Bone Densitometry">DEXA-Bone Densitometry</option>
                            <option value="Body Composition Analysis">Body Composition Analysis</option>
                            <option value="General and Vascular Ultrasound">General and Vascular Ultrasound</option>
                            <option value="Pediatric and Adult Sedation">Pediatric and Adult Sedation</option>
                            <option value="Iodine 131 Therapy">Iodine 131 Therapy</option>
                            <option value="DaTscan">DaTscan</option> --}}

                            <option value="BONE IMAGING THREE PHASE">BONE IMAGING THREE PHASE</option>

                            <option value="CAROTID DUPLEX">CAROTID DUPLEX</option>

                            <optgroup label="CT ABDOMEN AND PELVIS">
                                <option value="CT ABDOMEN AND PELVIS C-">CT ABDOMEN AND PELVIS C-</option>
                                <option value="CT ABDOMEN AND PELVIS C- C+">CT ABDOMEN AND PELVIS C- C+</option>
                                <option value="CT ABDOMEN AND PELVIS C+">CT ABDOMEN AND PELVIS C+</option>
                            </optgroup>

                            <optgroup label="CT ABDOMEN">
                                <option value="CT ABDOMEN C-">CT ABDOMEN C-</option>
                                <option value="CT ABDOMEN C- C+">CT ABDOMEN C- C+</option>
                                <option value="CT ABDOMEN C+">CT ABDOMEN C+</option>
                            </optgroup>

                            <optgroup label="CT BRAIN">
                                <option value="CT BRAIN C-">CT BRAIN C-</option>
                                <option value="CT BRAIN C- C+">CT BRAIN C- C+</option>
                                <option value="CT BRAIN C+">CT BRAIN C+</option>
                            </optgroup>

                            <optgroup label="CT CERVICAL SPINE">
                                <option value="CT CERVICAL SPINE C-">CT CERVICAL SPINE C-</option>
                            </optgroup>

                            <optgroup label="CT CHEST">
                                <option value="CT CHEST C-">CT CHEST C-</option>
                                <option value="CT CHEST C- C+">CT CHEST C- C+</option>
                                <option value="CT CHEST C+">CT CHEST C+</option>
                            </optgroup>

                            <optgroup label="CT CORONARY CALCIUM SCORING FOR MPI">
                                <option value="CT CORONARY CALCIUM SCORING FOR MPI">CT CORONARY CALCIUM SCORING FOR MPI</option>
                            </optgroup>

                            <optgroup label="CT HEART">
                                <option value="CT HEART C-">CT HEART C-</option>
                            </optgroup>

                            <optgroup label="CT LOWER EXTREMITY">
                                <option value= "CT LOWER EXTREMITY C-">CT LOWER EXTREMITY C-</option>
                                <option value= "CT LOWER EXTREMITY C+">CT LOWER EXTREMITY C+</option>
                            </optgroup>

                            <optgroup label="CT LT">
                                <option value="CT LT ANKLE C-">CT LT ANKLE C-</option>
                                <option value="CT LT HIP">CT LT HIP  C-</option>
                                <option value="CT LT KNEE C-">CT LT KNEE C-</option>
                                <option value="CT LT SHOULDER C-">CT LT SHOULDER C-</option>
                            </optgroup>

                            <optgroup label="CT LUMBAR SPINE">
                                <option value="CT LUMBAR SPINE C-">CT LUMBAR SPINE C -</option>
                                <option value="CT LUMBAR SPINE C- C+">CT LUMBAR SPINE C- C+</option>
                            </optgroup>

                            <optgroup label="CT MAXILLOFACIAL">
                                <option value="CT MAXILLOFACIAL C-">CT MAXILLOFACIAL C-</option>
                                <option value="CT MAXILLOFACIAL C- C+">CT MAXILLOFACIAL C- C+</option>
                                <option value="CT MAXILLOFACIAL C+">CT MAXILLOFACIAL C+</option>
                            </optgroup>

                            <optgroup label="CT NECK">
                                <option value="CT NECK C-">CT NECK C-</option>
                                <option value="CT NECK C- C+">CT NECK C- C+</option>
                                <option value="CT NECK C+">CT NECK C+</option>
                            </optgroup>

                            <optgroup label="CT ORBITS SELLA TEMP BONE">
                                <option value="CT ORBITS SELLA TEMP BONE C-">CT ORBITS SELLA TEMP BONE C-</option>
                                <option value="CT ORBITS SELLA TEMP BONE C- C+">CT ORBITS SELLA TEMP BONE C- C+</option>
                                <option value="CT ORBITS SELLA TEMP BONE C+">CT ORBITS SELLA TEMP BONE C+</option>
                            </optgroup>

                            <optgroup label="CT PELVIS">
                                <option value="CT PELVIS C-">CT PELVIS C-</option>
                                <option value="CT PELVIS C- C+">CT PELVIS C- C+</option>
                                <option value="CT PELVIS C+">CT PELVIS C+</option>
                            </optgroup>

                            <optgroup label="CT RT">
                                <option value="CT RT ANKLE C-">CT RT ANKLE C-</option>
                                <option value="CT RT ELBOW C-">CT RT ELBOW C-</option>
                                <option value="CT RT Foot C-">CT RT FOOT C-</option>
                                <option value="CT RT HIP C-">CT RT HIP C-</option>
                                <option value="CT RT KNEE C-">CT RT KNEE C-</option>
                                <option value="CT RT SHOULDER C-">CT RT SHOULDER C-</option>
                            </optgroup>

                            <optgroup label="CT THORACIC SPINE">
                                <option value="CT THORACIC SPINE C-">CT THORACIC SPINE C-</option>
                                <option value="CT THORACIC SPINE C- C+">CT THORACIC SPINE C- C+</option>
                            </optgroup>

                            <optgroup label="CT UPPER EXTREMITY">
                                <option value="CT UPPER EXTREMITY C-">CT UPPER EXTREMITY C-</option>
                            </optgroup>

                            <optgroup label="CTA ABDOMEN AND PELVIS">
                                <option>CTA ABDOMEN AND PELVIS C- C+</option>
                            </optgroup>

                            <optgroup label="CTA ABDOMEN">
                                <option>CTA ABDOMEN C- C+</option>
                            </optgroup>

                            <optgroup label="CTA CHEST">
                                <option>CTA CHEST C- C+</option>
                            </optgroup>

                            <optgroup label="CTA CORONARY">
                                <option>CTA CORONARY C+</option>
                            </optgroup>

                            <optgroup label="CTA HEAD">
                                <option>CTA HEAD C- C+</option>
                            </optgroup>

                            <optgroup label="CTA LOWER EXTREMETY">
                                <option>CTA LOWER EXTREMITY C- C+</option>
                            </optgroup>

                            <optgroup label="CTA NECK">
                                <option>CTA NECK C- C+</option>
                            </optgroup>

                            <optgroup label="CTA PELVIS">
                                <option>CTA PELVIS C- C+</option>
                            </optgroup>

                            <optgroup label="CTA RUNOFF">
                                <option>CTA RUNOFF + BIL EXT</option>
                            </optgroup>

                            <optgroup label="CTA UPPER EXTREMITY">
                                <option>CTA UPPER EXTREMITY C- C+</option>
                            </optgroup>

                            <optgroup label="CTV PELVIS">
                                <option>CTV PELVIS C- C+</option>
                            </optgroup>

                            <optgroup label="DEXA">
                                <option>DEXA ABSORPTIOMETRY WITH VFA</option>
                                <option>DEXA BODY COMPOSITION</option>
                                <option>DEXA BONE DENSITY</option>
                            </optgroup>

                            <optgroup label="HEPATOBIL SYST IMAGING W/WO RADIOPHARM">
                                <option>HEPATOBIL SYST IMAGING W/WO RADIOPHARM</option>
                            </optgroup>

                            <optgroup label="MRA">
                                <option>MRA ABDOMEN</option>
                                <option>MRA BRAIN C-</option>
                                <option>MRA BRAIN C- C+</option>
                                <option>MRA BRAIN C+</option>
                                <option>MRA CHEST</option>
                                <option>MRA LOWER EXTREMITY</option>
                                <option>MRA NECK C-</option>
                                <option>MRA NECK C- C+</option>
                                <option>MRA NECK C+</option>
                                <option>MRA PELVIS C- C+</option>
                                <option>MRA UPPER EXTREMITY C- C+</option>
                            </optgroup>

                            <optgroup label="MRI ABDOMEN">
                                <option>MRI ABDOMEN C-</option>
                                <option>MRI ABDOMEN C- C+</option>
                                <option>MRI ABDOMEN C+</option>
                            </optgroup>

                            <optgroup label="MRI BILATERAL">
                                <option>MRI BILATERAL BREAST C- C+</option>
                            </optgroup>

                            <optgroup label="MRI BRAIN">
                                <option>MRI BRAIN C-</option>
                                <option>MRI BRAIN C- C+</option>
                                <option>MRI BRAIN C- C+ | PITUITARY PROTOCOL</option>
                                <option>MRI BRAIN C+</option>
                            </optgroup>

                            <optgroup label="MRI CARDIAC">
                                <option>MRI CARDIAC C-</option>
                                <option>MRI CARDIAC C- C+</option>
                            </optgroup>

                            <optgroup label="MRI CERVICAL">
                                <option>MRI CERVICAL C-</option>
                                <option>MRI CERVICAL C- C+</option>
                                <option>MRI CERVICAL C+</option>
                            </optgroup>

                            <optgroup label="MRI CHEST">
                                <option>MRI CHEST C-</option>
                                <option>MRI CHEST C- C+</option>
                                <option>MRI CHEST C+</option>
                            </optgroup>

                            <optgroup label="MRI FETAL PART SINGLE OR FIRST GESTATION">
                                <option>MRI FETAL PART SINGLE OR FIRST GESTATION</option>
                            </optgroup>

                            <optgroup label="MRI JOINT LOWER EXTREMITY">
                                <option>MRI JOINT LOWER EXTREMITY C-</option>
                                <option>MRI JOINT LOWER EXTREMITY C-</option>
                                <option>MRI JOINT LOWER EXTREMITY C+</option>
                            </optgroup>

                            <optgroup label="MRI JOINT UPPER EXTREMITY">
                                <option>MRI JOINT UPPER EXTREMITY C-</option>
                                <option>MRI JOINT UPPER EXTREMITY C+</option>
                            </optgroup>

                            <optgroup label="MRI LOWER EXTREMITY">
                                <option>MRI LOWER EXTREMITY C</option>
                                <option>MRI LOWER EXTREMITY C- C+</option>
                                <option>MRI LOWER EXTREMITY C</option>
                            </optgroup>

                            <optgroup label="MRI LT ANKLE">
                                <option>MRI LT ANKLE C-</option>
                                <option>MRI LT ANKLE C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT ARM">
                                <option>MRI LT ARM C-</option>
                                <option>MRI LT ARM C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT CALF/LEG">
                                <option>MRI LT CALF/LEG C-</option>
                                <option>MRI LT CALF/LEG C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT ELBOW">
                                <option>MRI LT ELBOW C-</option>
                            </optgroup>

                            <optgroup label="MRI LT FOOT">
                                <option>MRI LT FOOT C-</option>
                                <option>MRI LT FOOT C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT FOREARM">
                                <option>MRI LT FOREARM C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT HAND">
                                <option>MRI LT HAND C-</option>
                            </optgroup>

                            <optgroup label="MRI LT HIP">
                                <option>MRI LT HIP C-</option>
                                <option>MRI LT HIP C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT KNEE">
                                <option>MRI LT KNEE C-</option>
                                <option>MRI LT KNEE C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT SHOULDER">
                                <option>MRI LT SHOULDER C-</option>
                                <option>MRI LT SHOULDER C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT THIGH">
                                <option>MRI LT THIGH C-</option>
                                <option>MRI LT THIGH C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LT WRIST">
                                <option>MRI LT WRIST C-</option>
                                <option>MRI LT WRIST C- C+</option>
                            </optgroup>

                            <optgroup label="MRI LUMBAR">
                                <option>MRI LUMBAR C-</option>
                                <option>MRI LUMBAR C- C+</option>
                                <option>MRI LUMBAR C+</option>
                            </optgroup>

                            <optgroup label="MRI ORBIT/FACE/NECK">
                                <option>MRI ORBIT/FACE/NECK C- C+</option>
                                <option>MRI ORBIT/FACE/NECK C+</option>
                                <option>MRI ORBITS/FACE/NECK C-</option>
                            </optgroup>

                            <optgroup label="MRI PELVIS">
                                <option>MRI PELVIS C- |  FEMALE</option>
                                <option>MRI PELVIS C- |  MALE</option>
                                <option>MRI PELVIS C- C+ |  FEMALE</option>
                                <option>MRI PELVIS C- C+ |  MALE</option>
                                <option>MRI PELVIS C+ |  FEMALE</option>
                                <option>MRI PELVIS C+ |  MALE</option>
                            </optgroup>

                            <optgroup label="MRI RT ANKLE">
                                <option>MRI RT ANKLE C-</option>
                                <option>MRI RT ANKLE C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT ARM">
                                <option>MRI RT ARM C-</option>
                                <option>MRI RT ARM C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT CALF/LEG">
                                <option>MRI RT CALF/LEG C-</option>
                                <option>MRI RT CALF/LEG C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT ELBOW">
                                <option>MRI RT ELBOW C-</option>
                            </optgroup>

                            <optgroup label="MRI RT FINGER">
                                <option>MRI RT FINGER(S) C-</option>
                            </optgroup>

                            <optgroup label="MRI RT FOOT">
                                <option>MRI RT FOOT C-</option>
                                <option>MRI RT FOOT C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT FOREARM">
                                <option>MRI RT FOREARM C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT HAND">
                                <option>MRI RT HAND C-</option>
                                <option>MRI RT HAND C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT HIP">
                                <option>MRI RT HIP C-</option>
                                <option>MRI RT HIP C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT KNEE">
                                <option>MRI RT KNEE C-</option>
                                <option>MRI RT KNEE C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT SHOULDER">
                                <option>MRI RT SHOULDER C-</option>
                                <option>MRI RT SHOULDER C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT THIGH">
                                <option>MRI RT THIGH C-</option>
                                <option>MRI RT THIGH C- C+</option>
                            </optgroup>

                            <optgroup label="MRI RT WRIST">
                                <option>MRI RT WRIST C-</option>
                                <option>MRI RT WRIST C- C+</option>
                            </optgroup>

                            <optgroup label="MRI THORACIC">
                                <option>MRI THORACIC C-</option>
                                <option>MRI THORACIC C- C+</option>
                            <option> MRI THORACIC C+</option>
                            </optgroup>

                            <optgroup label="MRI TM JOINTS">
                                <option>MRI TM JOINTS</option>
                            </optgroup>

                            <optgroup label="MRI UPPER EXTREMITY">
                                <option>MRI UPPER EXTREMITY C-</option>
                                <option>MRI UPPER EXTREMITY C- C+</option>
                                <option>MRI UPPER EXTREMITY C+</option>
                            </optgroup>

                            <optgroup label="MRV BRAIN">
                                <option>MRV BRAIN C-</option>
                                <option>MRV BRAIN C- C+</option>
                            </optgroup>

                            <optgroup label="NM">
                                <option>NM BONE IMAGING (SPECT)</option>
                                <option>NM BONE IMAGING THREE PHASE</option>
                                <option>NM BONE IMAGING WHOLE BODY</option>
                                <option>NM BRAIN TOMOGRAPHIC (SPECT)</option>
                                <option>NM CARDIAC BLOOD POOL MULTIPLE</option>
                                <option>NM DATSCAN</option>
                                <option>NM GALLIUM RADIOPHARM. LOCALIZATION INFLAMATORY PROC</option>
                                <option>NM GASTRIC EMPTYING STUDY</option>
                                <option>NM HEPATOBIL SYST IMAGING W/WO RADIOPHARM</option>
                                <option>NM KIDNEY STATIC FLOW FUNCTION WITH DRUG</option>
                                <option>NM LIVER AND SPLEEN	78216</option>
                                <option>NM MYOCARDIAL PERFUSION STRESS OR REST MULTIPLE STUDY</option>
                                <option>NM OCTREOSCAN</option>
                                <option>NM PARATHYROID PLANAR IMAGING</option>
                                <option>NM PULMONARY PERFUSION IMAGING</option>
                                <option>NM THALLIUM REST MYOCARDIAL PERFUSION</option>
                                <option>NM THYROID CANCER</option>
                                <option>NM THYROID IMAGING WITH VASCULAR FLOW</option>
                                <option>NM WHOLE BODY I-131 IMAGING</option>
                                <option>NM WHOLE BODY TUMOR IMAGING - SINGLE DAY IMAGING</option>
                            </optgroup>

                            <optgroup label="PET CT">
                                <option>PET CT LIMITED AREA</option>
                                <option>PET CT SKULL BASE TO MID-THIGH</option>
                                <option>PET CT WHOLE BODY</option>
                            </optgroup>

                            <optgroup label="ULTRASOUND">
                                <option>ULTRASOUND ABDOMEN AORTA</option>
                                <option>ULTRASOUND ABDOMEN COMPLETE</option>
                                <option>ULTRASOUND ABDOMEN LIMITED</option>
                                <option>ULTRASOUND ARTERIES DUPLEX LOWER EXTREMITY</option>
                                <option>ULTRASOUND ARTERIES DUPLEX UPPER EXTREMITY</option>
                                <option>ULTRASOUND ARTERIES DUPLEX UPPER EXTREMITY LIMITED</option>
                                <option>ULTRASOUND BREAST UNILATERAL COMPLETE</option>
                                <option>ULTRASOUND CAROTID DUPLEX</option>
                                <option>ULTRASOUND CHEST</option>
                                <option>ULTRASOUND DUPLEX AORTA INF VENA CAV</option>
                                <option>ULTRASOUND EXTREMITY COMPLETE</option>
                                <option>ULTRASOUND EXTREMITY LIMITED-AXILLARY</option>
                                <option>ULTRASOUND HEAD NECK BRAIN</option>
                                <option>ULTRASOUND PELVIC COMPLETE</option>
                                <option>ULTRASOUND PELVIC LIMITED</option>
                                <option>ULTRASOUND RENAL</option>
                                <option>ULTRASOUND RENAL</option>
                                <option>ULTRASOUND RENAL (RENAL AORTA)</option>
                                <option>ULTRASOUND RENAL DOPPLER</option>
                                <option>ULTRASOUND RETROP (RENAL AORTA NODES)</option>
                                <option>ULTRASOUND SCROTUM</option>
                                <option>ULTRASOUND TRANSRECTAL</option>
                                <option>ULTRASOUND TRANSVAGINAL</option>
                                <option>ULTRASOUND VENOUS DUPLEX</option>
                                <option>ULTRASOUND VENOUS DUPLEX UNILATERAL</option>
                            </optgroup>

                        </select>

                    </div>
                    <div class="form-group col-sm-2">
                        <select class="js-example-placeholder-multiple js-states custom-select" id="service-code" name="code">
                            <option selected>{{ old('code') }}</option>

                            <optgroup label="BONE IMAGING THREE PHASE">
                                <option>78315</option>
                            </optgroup>

                            <optgroup label="CAROTID DUPLEX">
                                <option>93880</option>
                            </optgroup>

                            <optgroup label="CT ABDOMEN AND PELVIS">
                                <option>74176</option>
                                <option>74178</option>
                                <option>74177</option>
                            </optgroup>

                            <optgroup label="CT ABDOMEN">
                                <option>74150</option>
                                <option>74170</option>
                                <option>74160</option>
                            </optgroup>

                            <optgroup label="CT BRAIN">
                                <option>70450</option>
                                <option>70470</option>
                                <option>70460</option>
                            </optgroup>

                            <optgroup label="CT CERVICAL SPINE C-">
                                <option>72125</option>
                            </optgroup>

                            <optgroup label="CT CHEST">
                                <option>71250</option>
                                <option>71270</option>
                                <option>71260</option>
                            </optgroup>

                            <optgroup label="CT CORONARY CALCIUM SCORING FOR MPI">
                                <option>755710</option>
                            </optgroup>
                            <optgroup label="CT HEART C-">
                                <option>75571</option>
                            </optgroup>


                            <optgroup label="CT LOWER EXTREMITY">
                                <option>73700</option>
                                <option>73701</option>
                            </optgroup>


                            <optgroup label="CT LT">
                                <option>737001</option>
                                <option>737004</option>
                                <option>737005</option>
                                <option>732006</option>
                            </optgroup>

                            <optgroup label="CT LUMBAR SPINE">
                                <option>72131</option>
                                <option>72133</option>
                            </optgroup>

                            <optgroup label="CT MAXILLOFACIAL">
                                <option>70486</option>
                                <option>70488</option>
                                <option>70487</option>
                            </optgroup>

                            <optgroup label="CT NECK">
                                <option>70490</option>
                                <option>70492</option>
                                <option>70491</option>
                            </optgroup>

                            <optgroup label="CT ORBITS SELLA TEMP BONE">
                                <option>70480</option>
                                <option>70482</option>
                                <option>70481</option>
                            </optgroup>

                            <optgroup label="CT PELVIS">
                                <option>72192</option>
                                <option>72194</option>
                                <option>72193</option>
                            </optgroup>

                            <optgroup label="CT RT">
                                <option value="">737007</option>
                                <option value="">732009</option>
                                <option value="">737009</option>
                                <option value="">7370010</option>
                                <option value="">7370011</option>
                                <option value="">7320013</option>
                            </optgroup>

                            <optgroup label="CT THORACIC SPINE">
                                <option value="">72128</option>
                                <option value="">72130</option>
                            </optgroup>

                            <optgroup label="CT UPPER EXTREMITY">
                                <option value="">73200</option>
                            </optgroup>

                            <optgroup label="CTA ABDOMEN AND PELVIS">
                                <option>74174</option>
                            </optgroup>

                            <optgroup label="CTA ABDOMEN">
                                <option>74175</option>
                            </optgroup>

                            <optgroup label="CTA CHEST">
                                <option>71275</option>
                            </optgroup>

                            <optgroup label="CTA CORONARY">
                                <option>75574</option>
                            </optgroup>

                            <optgroup label="CTA HEAD">
                                <option>70496</option>
                            </optgroup>

                            <optgroup label="CTA LOWER EXTREMITY">
                                <option>73706</option>
                            </optgroup>

                            <optgroup label="CTA NECK">
                                <option>70498</option>
                            </optgroup>

                            <optgroup label="CTA PELVIS">
                                <option>72191</option>
                            </optgroup>

                            <optgroup label="CTA RUNOFF">
                                <option>75635</option>
                            </optgroup>

                            <optgroup label="CTA UPPER EXTREMITY">
                                <option>73206</option>
                            </optgroup>

                            <optgroup label="CTV PELVIS">
                                <option>721911</option>
                            </optgroup>

                            <optgroup label="DEXA">
                                <option>77085</option>
                                <option>76499</option>
                                <option>77080</option>
                            </optgroup>

                            <optgroup label="HEPATOBIL SYST IMAGING W/WO RADIOPHARM">
                                <option>78227</option>
                            </optgroup>

                            <optgroup label="MRA">
                                <option>74185</option>
                                <option>70544</option>
                                <option>70546</option>
                                <option>70545</option>
                                <option>71555</option>
                                <option>73725</option>
                                <option>70547</option>
                                <option>70549</option>
                                <option>70548</option>
                                <option>72198</option>
                                <option>73225</option>
                            </optgroup>

                            <optgroup label="MRI ABDOMEN">
                                <option>74181</option>
                                <option>74183</option>
                                <option>74182</option>
                            </optgroup>

                            <optgroup label="MRI BILATERAL">
                                <option>77049</option>
                            </optgroup>

                            <optgroup label="MRI BRAIN">
                                <option>70551</option>
                                <option>70553</option>
                                <option>705531</option>
                                <option>70552</option>
                            </optgroup>

                            <optgroup label="MRI CARDIAC">
                                <option>75557</option>
                                <option>75561</option>
                            </optgroup>

                            <optgroup label="MRI CERVICAL">
                                <option>72141</option>
                                <option>72156</option>
                                <option>72142</option>
                            </optgroup>

                            <optgroup label="MRI CHEST">
                                <option>71550</option>
                                <option>71552</option>
                                <option>71551</option>
                            </optgroup>

                            <optgroup label="MRI FETAL PART SINGLE OR FIRST GESTATION">
                                <option>74712</option>
                            </optgroup>

                            <optgroup label="MRI JOINT LOWER EXTREMITY">
                                <option>73721</option>
                                <option>73721</option>
                                <option>73722</option>
                            </optgroup>

                            <optgroup label="MRI JOINT UPPER EXTREMITY">
                                <option>73221</option>
                                <option>73222</option>
                            </optgroup>

                            <optgroup label="MRI LOWER EXTREMITY">
                                <option>73718</option>
                                <option>73720</option>
                                <option>73719</option>
                            </optgroup>

                            <optgroup label="MRI LT ANKLE">
                                <option>737211</option>
                                <option>737231</option>
                            </optgroup>

                            <optgroup label="MRI LT ARM">
                                <option>732181</option>
                                <option>732201</option>
                            </optgroup>

                            <optgroup label="MRI LT CALF/LEG">
                                <option>737181</option>
                                <option>737201</option>
                            </optgroup>

                            <optgroup label="MRI LT ELBOW">
                                <option>732211</option>
                            </optgroup>

                            <optgroup label="MRI LT FOOT">
                                <option>737212</option>
                                <option>737232</option>
                            </optgroup>

                            <optgroup label="MRI LT FOREARM">
                                <option>732202</option>
                            </optgroup>

                            <optgroup label="MRI LT HAND">
                                <option>732213</option>
                            </optgroup>

                            <optgroup label="MRI LT HIP">
                                <option>737213</option>
                                <option>737233</option>
                            </optgroup>

                            <optgroup label="MRI LT KNEE">
                                <option>737214</option>
                                <option>737234</option>
                            </optgroup>

                            <optgroup label="MRI LT SHOULDER">
                                <option>732214</option>
                                <option>732234</option>
                            </optgroup>

                            <optgroup label="MRI LT THIGH">
                                <option>737184</option>
                                <option>737204</option>
                            </optgroup>

                            <optgroup label="MRI LT WRIST">
                                <option>732215</option>
                                <option>732235</option>
                            </optgroup>

                            <optgroup label="MRI LUMBAR">
                                <option>72148</option>
                                <option>72158</option>
                                <option>72149</option>
                            </optgroup>

                            <optgroup label="MRI ORBIT/FACE/NECK">
                                <option>70543</option>
                                <option>70542</option>
                                <option>70540</option>
                            </optgroup>

                            <optgroup label="MRI PELVIS">
                                <option>721951</option>
                                <option>721952</option>
                                <option>721971</option>
                                <option>721972</option>
                                <option>721961</option>
                                <option>721962</option>
                            </optgroup>

                            <optgroup label="MRI RT ANKLE">
                                <option>737215</option>
                                <option>737235</option>
                            </optgroup>

                            <optgroup label="MRI RT ARM">
                                <option>732185</option>
                                <option>732205</option>
                            </optgroup>

                            <optgroup label="MRI RT CALF/LEG">
                                <option>737185</option>
                                <option>737205</option>
                            </optgroup>

                            <optgroup label="MRI RT ELBOW">
                                <option>732216</option>
                            </optgroup>

                            <optgroup label="MRI RT FINGER">
                                <option>732217</option>
                            </optgroup>

                            <optgroup label="MRI RT FOOT">
                                <option>737216</option>
                                <option>737236</option>
                            </optgroup>

                            <optgroup label="MRI RT FOREARM">
                                <option>732206</option>
                            </optgroup>

                            <optgroup label="MRI RT HAND">
                                <option>732218</option>
                                <option>732238</option>
                            </optgroup>

                            <optgroup label="MRI RT HIP">
                                <option>737217</option>
                                <option>737237</option>
                            </optgroup>

                            <optgroup label="MRI RT KNEE">
                                <option>737218</option>
                                <option>737238</option>
                            </optgroup>

                            <optgroup label="MRI RT SHOULDER">
                                <option>732219</option>
                                <option>732239</option>
                            </optgroup>

                            <optgroup label="MRI RT THIGH">
                                <option>737188</option>
                                <option>737208</option>
                            </optgroup>

                            <optgroup label="MRI RT WRIST">
                                <option>7322110</option>
                                <option>7322310</option>
                            </optgroup>

                            <optgroup label="MRI THORACIC">
                                <option>72146</option>
                                <option>72157</option>
                                <option>72147</option>
                            </optgroup>

                            <optgroup label="MRI TM JOINTS">
                                <option>70336</option>
                            </optgroup>

                            <optgroup label="MRI UPPER EXTREMITY">
                                <option>73218</option>
                                <option>73220</option>
                                <option>73219</option>
                            </optgroup>

                            <optgroup label="MRV BRAIN">
                                <option>705441</option>
                                <option>705461</option>
                            </optgroup>

                            <optgroup label="NM">
                                <option>78803</option>
                                <option>78315</option>
                                <option>78306</option>
                                <option>788031</option>
                                <option>78473</option>
                                <option>788032</option>
                                <option>788321</option>
                                <option>78264</option>
                                <option>78227</option>
                                <option>78708</option>
                                <option>78216</option>
                                <option>78452</option>
                                <option>788033</option>
                                <option>78072</option>
                                <option>78580</option>
                                <option>78466</option>
                                <option>78018</option>
                                <option>78013</option>
                                <option>780181</option>
                                <option>78832</option>
                            </optgroup>

                            <optgroup label="PET CT">
                                <option>78814</option>
                                <option>78815</option>
                                <option>78816</option>
                            </optgroup>

                            <optgroup label="ULTRASOUND">
                                <option>76706</option>
                                <option>76700</option>
                                <option>76705</option>
                                <option>93925</option>
                                <option>93930</option>
                                <option>93931</option>
                                <option>76641</option>
                                <option>93880</option>
                                <option>76604</option>
                                <option>93978</option>
                                <option>76881</option>
                                <option>76882</option>
                                <option>76536</option>
                                <option>76856</option>
                                <option>76857</option>
                                <option>76770</option>
                                <option>767700</option>
                                <option>767700</option>
                                <option>767700</option>
                                <option>76770</option>
                                <option>76870</option>
                                <option>76872</option>
                                <option>76830</option>
                                <option>93970</option>
                                <option>93971</option>
                            </optgroup>
                            {{-- <optgroup label="MRI">
                                <option>1520</option>
                                <option>6532</option>
                            </optgroup>
                            <optgroup label="MRA">
                            </optgroup>
                            <optgroup label="CTA">
                                <option>75214</option>
                                <option>6452</option>
                                <option>6540</option>
                            </optgroup>
                            <optgroup label="Dual Sorce CT">
                                <option>5632</option>
                            </optgroup>
                            <optgroup label="CTA">
                                <option>4879</option>
                            </optgroup>
                            <optgroup label="Nuclear Medicine">
                                <option>7854</option>
                            </optgroup>
                            <optgroup label="SPECT-CT">
                                <option>3456</option>
                            </optgroup>
                            <optgroup label="PET-CT">
                                <option>9514</option>
                            </optgroup>
                            <optgroup label="DEXA-Bone Densitometry">
                                <option>3547</option>
                            </optgroup>
                            <optgroup label="Body Composition Analysis">
                                <option>2587</option>
                            </optgroup>
                            <optgroup label="General and Vascular Ultrasound">
                            </optgroup>
                            <optgroup label="Pediatric and Adult Sedation">
                            </optgroup>
                            <optgroup label="Iodine 131 Therapy">
                            </optgroup>
                            <optgroup label="DaTscan">
                            </optgroup> --}}
                        </select>
                    </div>
                    <div class="form-group col-md-4 custom-file">
                        <input name="medical_order" type="file" class="form-control-file" id="inputGroupFile01" required value="{{ old('medical_order') }}">
                        {{--  input class="custom-file-input"  --}}
                        <label class="" for="inputGroupFile01">Escoger Orden Medica</label>
                    </div>
                </div>
                <input type="text" hidden value="4" name="activity">
                <button type="submit" class="btn btn-primary">Submit</button>
            </div>
        </form>
    </div>
</div>
@endsection
{{--    --}}
@section('script')
    <script>

        $('#checkboxid').change(function(){
            if(this.checked){
            $('.aplica').removeAttr("disabled");
            $('.aplica').removeAttr("hidden");
            }
        });

        function checkaplica(){
            var check = document.getElementById('checkboxid');
            if(checkaplica.check != true){
                $('.checkbox').val(1);
            }
        }

        var medplan = $(".medplan").val();
        $('select[name="plan_name"]').change(function(){

            {{-- if($(this).val() == "MMM"){
                $('.mp-id').attr("placeholder", "ID MMM");
                $('.mp-group').attr("placeholder", "RxGrp: #")
             }

            if($(this).val() == "Humana"){
                $('.mp-id').attr("placeholder", "ID Humana");
                $('.mp-group').attr("placeholder", "Group ID: #")
            }

            if($(this).val() == "First Medical"){
                $('.mp-id').attr("placeholder", "ID First Medical");
                $('.mp-group').attr("placeholder", "RX GROUP: #")
            } --}}
        })

        //2nd Med Plan changes
        var medplan = $(".medplan2").val();
        $('select[name="plan_name2nd"]').change(function(){
            if($(this).val() == "MMM"){
                $('.mp-id2').attr("placeholder", "ID MMM");
                $('.mp-group2').attr("placeholder", "RxGrp: #")
            }

            if($(this).val() == "Humana"){
                $('.mp-id2').attr("placeholder", "ID Humana");
                $('.mp-group2').attr("placeholder", "Group ID: #")
            }

            if($(this).val() == "First Medical"){
                $('.mp-id2').attr("placeholder", "ID First Medical");
                $('.mp-group2').attr("placeholder", "RX GROUP: #")
            }
        })
        //
        $(".js-example-placeholder-multiple").select2({
            placeholder: "Select Code:",
            allowClear: true
        });

    </script>
@endsection