The Routine Antenatal Diagnostic Imaging With Ultrasound Study (RADIUS) has reported that the adoption of routine screening in the United States would add considerably to health care costs, but stated that a potential benefit may be identification of fetal anomalies. To determine whether the cost per detected malformed fetus using data from the RADIUS study is cost-effective, a comparison is made with the California maternal serum alpha-fetoprotein (MSAFP) screening program. When screening ultrasound is performed by individuals who have a diagnostic rate similar to that reported for tertiary centers that participated in the RADIUS study (6.8 per 1000), the cost for identifying a malformed fetus is $10,805 less ($200 per ultrasound examination) than the cost using MSAFP screening ($40,338; $53 per test). However, when the screening examination is performed by individuals whose diagnostic rate is similar to that reported for non-tertiary centers (1.7 per 1000) that participated in the RADIUS study, the cost for identifying a malformed fetus ($115,575) is $75,237 higher than MSAFP screening. Using data from the RADIUS study, a proposal is suggested by which physicians are reimbursed for second-trimester ultrasound based upon their diagnostic skills. This approach maintains the cost per detected malformed fetus at less than $30,000, decreases the current cost of diagnostic ultrasound to third-party payers, and allows second-trimester ultrasound to be offered as a cost-effective screening test for low-risk patients for identification of malformed fetuses.