pay a $3.8 million settlement to the Department of Justice and $7.4 million class action lawsuit. Another contributing factor to overutilization is a lack of real time cost available to both the physician and the patient. Physicians are unable to ascertain the true cost of a screening, imaging, or lab test thereby making it difficult for them to determine how much they are charging the system. Effects of overutilization on patients can include unnecessary radiation exposure and false positive results. Initiatives are underway to curtail excessive screenings that have been deemed unnecessary, such as limiting prostate cancer screening as the United States Preventive Services Task Force recently found inadequate evidence to determine whether treatment for prostate cancer detected by screening actually improves health outcomes. Studies in geographic variation have shown no difference in patient outcomes between physicians who practice in high cost areas and those who practice in low cost areas. A 2009 American Board of Radiology Foundation summit to address overutilization also identified defensive medicine and patients as contributory factors to the issue. Defensive medicine is an order for imaging as a result of potential malpractice, rather than benefit to the patient. It has been estimated to account for 5-25% of all imaging costs. Patient demand often stems from little financial responsibility for costs associated with imaging, as well as information from other individuals, radio, the media, and the Internet with disproportionate understanding of the implications of imaging (further testing, exposure to radiation). Patients are being targeted to "self-present" to imaging facilities for uncovered imaging services that claim to offer screen for undetected coronary artery disease and cancer in the lungs and other organs. However, the false positives observed for CT screening of coronary artery disease are similar to the levels of other noninvasive tests for ischemic heart disease and some data indicate these services do not yield more precise results. For instance, data from electron-beam CT did not outperform the Framingham Risk Index for predicting coronary events.8 Researchers suggest that the use of CT scanning for cancer screening cannot offer patients complete "peace of mind" as there are still issues of sensitivity and specificity, raising concerns over the implications of false negatives. Concerns over overutilization of diagnostic tests have prompted the definition of "high value care" as the health benefits of an intervention justifies its harms and costs. Some examples of low value care include a repeat ultrasonography