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Objective. Compare health care utilization and charges for low-back-pain (LBP) patients receiving advanced imaging or physical therapy as a first management strategy following a new primary care consultation. Data Source. Electronic medical record (EMR) and insurance claims data. Study Design. Retrospective analysis of propensity-matched groups. Data Collection/Extraction. Claims and EMR data were used. Utilization and LBP-related charges over a 1-year period were extracted from claims data. Principal Findings. In the propensity-matched sample [n = 406), advanced imaging recipients had higher odds of all utilization outcomes. Charges were higher with advanced imaging by an average $4,793 (95 percent CI: $3,676, $5,910). Conclusions. For patients with LBP whom newly consulted primary care referred for additional management, advanced imaging as a first management was associated with higher health care utilization and charges than physical therapy. Key Words. Physical therapy, low back pain, primary care, imaging, Low back pain (LBP) imposes a large socioeconomic burden on individuals and health care systems. Average annual direct costs per individual are estimated from $1,500 to $2,000 (Fritz et al. [...]