label">Jenis</label>
              <div class="col-sm-4">
                <input type="hidden" name="kd_jenis_prw_eresep" class="form-control" value="">
                <input type="text" name="nm_perawatan_eresep" class="form-control" placeholder="Nama Obat/BHP/Racikan" value="" readonly>
              </div>
              <label for="pnd" class="col-sm-2 control-label">Biaya</label>
              <div class="col-sm-3">
                <input type="text" id="biaya_eresep" name="biaya_eresep" class="form-co