Every patient that comes to Radiology has a different category of health problem. Based on diagnoses, each patient gets the appropriate imaging to aid in their treatment. The Healthier Hospital Initiative (HHI, www.healthierhospitals.org), Healthcare Without Harm (www.https://noharm.org/), and Practice Greenhealth (www.https://practicegreenhealth.org/) are important efforts on the part of healthcare providers to move toward sustainability. This initiative has raised awareness of energy utilization, and provides tools for measuring hospital energy use. However, the coupling of patient healthcare teams (RN, MD, administrators) making the decisions that achieve quality patient care, with a goal of lower environmental impact has yet to be widely explored. This study examines the use of the American College of Radiology (ACR) Appropriateness Criteria as guidance for similar, “usually appropriate” imaging modality choices (that is, ratings of 7, 8, and 9) and then identifies which is the lower energy use modality alternative. Overall, in the ten ACR patient categories (with 162 subcategories which have overall 810 variants), there are approximately 48% of patient conditions where there are similar imaging modalities with a “usually appropriate” rating. The largest percentage interchangeability is in the cardiac category. Thus the potential to choose a lower energy imaging alternative appears to exist. As examples, six patient variants are used to illustrate the potential to reduce Radiology Department energy use. These examples provide approximate energy reduction imaging alternatives that if selected, in even 1%–10% of patient cases, (versus the 48% of comparative “usually appropriate” imaging) would lead to an annual U.S. healthcare improvement of 24–240 million kWh per year. This modest improvement would be a direct contribution to healthcare sustainability by the Radiology community without any technology change.