This study aims to evaluate trends in utilization of image guidance for intraarticular hip injections and to compare the cost efficiency of ultrasound-, fluoroscopic-, and landmark-guided injections in the management of hip osteoarthritis (OA) and femoroacetabular impingement (FAI).Retrospective descriptive epidemiology study.The information was collected from Humana private payer insurance claims database encompassing all practice settings.A total of 302 855 patients for years 2007 to 2015. INTERVENTIONS OR ASSESSMENT OF RISK FACTORS OR INDEPENDENT VARIABLES:: Primary diagnosis of hip OA or FAI.Injection type [corticosteroid (CS) or hyaluronic acid (HA)], imaging modality (landmark, ultrasound, or fluoroscopic guidance), and costs.Landmark-guided CS and HA injections for the management of hip OA decreased, whereas fluoroscopic and ultrasound guidance increased. Similar trends were demonstrated in the management of FAI using CS. In the management of FAI using HA, landmark- and ultrasound-guided injections decreased and fluoroscopic-guided injections increased. Cost analysis revealed lower reimbursement of landmark and ultrasound guidance compared with fluoroscopic guidance.During the study period, there was an increase in the use of image guidance and decline in landmark guidance for the treatment of OA and FAI using CS and HA. Fluoroscopic guidance demonstrated increased reimbursement compared with landmark and fluoroscopic guidance. There is an opportunity to mitigate cost and reduce radiation exposure by using ultrasound-guided injections rather than fluoroscopic guidance.