calculation table Item Amount Submitted charge (based on provider’s regular fee) $650 Medicare-participating physician fee schedule allowed amount $450 Medicare Non-participating physician allowed amount (MPFS allowed amount, less 5 percent) Medicare payment (80% of MPFS allowed, less 5 percent) $ Limiting charge to patient $ [MPFS – (MPFS x 5 percent)] x 115 percent Patient payment $ (balance of the limiting charge minus Medicare payment) Provider write-off $