<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no" />
<meta http-equiv="x-ua-compatible" content="ie=edge" />
<title>Material Design for Bootstrap</title>
<!-- MDB icon -->
<link rel="icon" href="img/mdb-favicon.ico" type="image/x-icon" />
<!-- Font Awesome -->
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.15.2/css/all.css" />
<!-- Google Fonts Roboto -->
<link rel="stylesheet" href="https://fonts.googleapis.com/css2?family=Roboto:wght@300;400;500;700;900&display=swap" />
<!-- MDB -->
<link rel="stylesheet" href="css/bootstrap-payment-forms.min.css" />
</head>
<body>
<!-- Start your project here-->
<style>
.btn-group-vertical>.btn:not(:first-child),
.btn-group-vertical>.btn-group:not(:first-child) {
margin-top: 0;
}
</style>
<section>
<div class="d-flex justify-content-between align-items-center mb-5">
<div class="d-flex flex-row align-items-center">
<h4 class="text-uppercase mt-1">Eligible</h4>
<span class="ms-2 me-3">Pay</span>
</div>
<a href="#!">Cancel and return to the website</a>
</div>
<div class="row">
<div class="col-md-7 col-lg-7 col-xl-6 mb-4 mb-md-0">
<h5 class="mb-0 text-success">$85.00</h5>
<h5 class="mb-3">Diabites Pump & Supplies</h5>
<div>
<div class="d-flex justify-content-between">
<div class="d-flex flex-row mt-1">
<h6>Insurance Responsibility</h6>
<h6 class="fw-bold text-success ms-1">$71.76</h6>
</div>
<div class="d-flex flex-row align-items-center text-primary">
<span class="ms-1">Add Insurer card</span>
</div>
</div>
<p>
Insurance claim and all neccessary dependencies will be submitted to your
insurer for the covered portion of this order.
</p>
<div
class="p-2 d-flex justify-content-between align-items-center"
style="background-color: #eee;"
>
<span>Aetna - Open Access</span>
<span>Aetna - OAP</span>
</div>
<hr />
<div class="d-flex justify-content-between align-items-center">
<div class="d-flex flex-row mt-1">
<h6>Patient Balance</h6>
<h6 class="fw-bold text-success ms-1">$13.24</h6>
</div>
<div class="d-flex flex-row align-items-center text-primary">
<span class="ms-1">Add Payment card</span>
</div>
</div>
<p>
Insurance claim and all neccessary dependencies will be submitted to your
insurer for the covered portion of this order.
</p>
<div class="d-flex flex-column mb-3">
<div class="btn-group-vertical" role="group" aria-label="Vertical button group">
<input
type="radio"
class="btn-check"
name="options"
id="option1"
autocomplete="off"
/>
<label class="btn btn-outline-primary btn-lg" for="option1">
<div class="d-flex justify-content-between">
<span>VISA </span>
<span>**** 5436</span>
</div>
</label>
<input
type="radio"
class="btn-check"
name="options"
id="option2"
autocomplete="off"
checked
/>
<label class="btn btn-outline-primary btn-lg" for="option2">
<div class="d-flex justify-content-between">
<span>MASTER CARD </span>
<span>**** 5038</span>
</div>
</label>
</div>
</div>
<div class="btn btn-success btn-lg btn-block">Proceed to payment</div>
</div>
</div>
<div class="col-md-5 col-lg-4 col-xl-4 offset-lg-1 offset-xl-2">
<div class="p-3" style="background-color: #eee;">
<span class="fw-bold">Order Recap</span>
<div class="d-flex justify-content-between mt-2">
<span>contracted Price</span> <span>$186.86</span>
</div>
<div class="d-flex justify-content-between mt-2">
<span>Amount Deductible</span> <span>$0.0</span>
</div>
<div class="d-flex justify-content-between mt-2">
<span>Coinsurance(0%)</span> <span>+ $0.0</span>
</div>
<div class="d-flex justify-content-between mt-2">
<span>Copayment </span> <span>+ 40.00</span>
</div>
<hr />
<div class="d-flex justify-content-between mt-2">
<span class="lh-sm"
>Total Deductible,<br />
Coinsurance and copay
</span>
<span>$40.00</span>
</div>
<div class="d-flex justify-content-between mt-2">
<span class="lh-sm"
>Maximum out-of-pocket <br />
on insurance policy</span
>
<span>$40.00</span>
</div>
<hr />
<div class="d-flex justify-content-between mt-2">
<span>Insurance Responsibility </span> <span>$71.76</span>
</div>
<div class="d-flex justify-content-between mt-2">
<span>Patient Balance </span> <span>$13.24</span>
</div>
<hr />
<div class="d-flex justify-content-between mt-2">
<span>Total </span> <span class="text-success">$85.00</span>
</div>
</div>
</div>
</div>
</section>
<!-- End your project here-->
<!-- MDB -->
<script type="text/javascript" src="js/mdb.min.js"></script>
<!-- Custom scripts -->
<script type="text/javascript"></script>
</body>
</html>