This paper reports findings from Nationwide Evaluation of X-ray Trends surveys conducted in 2001, 2002, and 2003 of clinical facilities that perform routine radiographic examinations of the adult chest, abdomen, lumbosacral spine, and upper gastrointestinal fluoroscopic examinations. Randomly identified clinical facilities were surveyed in approximately 40 participating states. For the surveyed radiographic exams, additional facilities that use computed radiography or digital radiography were surveyed to ensure adequate sample sizes for determining comparative statistics. State radiation control personnel performed site visits and collected data on patient exposure, radiographic/fluoroscopic technique factors, image quality, and quality-control and quality-assurance practices. Results of the NEXT surveys are compared with those of previous surveys conducted in 1964 and 1970 by the U.S. Public Health Service and the Food and Drug Administration. An estimated 155 million routine adult chest exams were performed in 2001. Average patient entrance skin air kerma from chest radiography at facilities using digital-based imaging modalities was found to be significantly higher (p < 0.001), but not so for routine abdomen or lumbosacral spine radiography. Digital-based imaging showed a substantial reduction in patient exposure for the radiographic portion of the routine upper gastrointestinal fluoroscopy exam. Long-term trends in surveyed diagnostic examinations show that average patient exposures are at their lowest levels. Of concern is the observation that a substantial fraction of surveyed non-hospital sites indicated they do not regularly have a medical physics survey conducted on their radiographic equipment. These facilities are likely unaware of the radiation doses they administer to their patients.