- What the Blueprint Actually Is
- The Three Domains at a Glance
- Domain 1: Patient Care (16 Scored Questions)
- Domain 2: Image Production (105 Scored Questions)
- Domain 3: Procedures (64 Scored Questions)
- How Questions Are Delivered
- Scoring, the 75 Standard, and Pass-Rate Context
- Eligibility and Fee Mechanics That Shape Your Timeline
- Sequencing Your Prep Around the Blueprint
- Where the Credential Is Used
- Frequently Asked Questions
- The exam has three official domains: Patient Care (16 scored), Image Production (105), and Procedures (64).
- Image Production is the largest domain, split into Basic Principles of Ultrasound (32), Image Formation (37), and Representative Images (36).
- The test has 225 questions, but only 185 are scored; 40 are unscored pilot items.
- A passing score is 75 on the 1-99 scaled system, not 75% of questions correct.
What the Blueprint Actually Is
The exam this site calls "RTBS" is the ARRT postprimary Breast Sonography (BS) credential, awarded by the American Registry of Radiologic Technologists. It is a different credential from ARDMS Breast (BR) and from ARRT's general Sonography (S) certification, and the distinction matters because the content outlines do not match. If you want the broader identity question answered first, start with What Is RTBS Certification? and then return here for the content breakdown.
The official exam-objective source is the Breast Sonography Examination Content Specifications, board approved in July 2025, effective September 1, 2026 (version v2025.10.16). Everything in this guide is anchored to that document. It lists three major examination categories and assigns each a number of scored questions. We keep those as counts rather than converting them to percentages, because the specifications publish counts and any percentage you see elsewhere is an inference.
The Three Domains at a Glance
| Domain | Scored Questions | Role in the Exam |
|---|---|---|
| Patient Care | 16 | Smallest domain; professional and safety fundamentals |
| Image Production | 105 | Largest domain; physics, image formation, and image selection |
| Procedures | 64 | Breast imaging protocols, anatomy, pathology, and interventional support |
The three counts add up to the 185 scored questions on your form. The remaining 40 questions are unscored pilot items that look identical to scored ones, so you cannot tell which is which and should treat every item seriously. For a deeper look at how this structure affects overall difficulty, see How Hard Is the RTBS Exam?
Domain 1: Patient Care (16 Scored Questions)
Patient Care is the smallest slice of the exam, but do not dismiss it. Sixteen scored questions is a realistic place to pick up points that cost little study time, especially if you already work in a clinical imaging environment.
Patient Care: What Candidates Must Understand
Expect questions that test whether you can communicate and protect patients in the specific context of breast imaging, which carries unusual emotional and privacy weight.
- Patient identification, history gathering, and documenting symptoms such as a palpable lump, pain, or nipple discharge
- Communication with anxious patients, including those returning for a callback from screening
- Infection control and equipment cleaning between exams
- Patient safety, positioning comfort, and appropriate draping and privacy
- Ethics and professional boundaries, including the limits of what a sonographer may tell a patient about findings
That last point deserves emphasis. The registry's framework is that mandatory exams are presented to the radiologist for final interpretation, so scenario questions often hinge on knowing what falls inside the technologist's role and what does not. This same ethics framework underlies the ARRT ethics compliance requirement you must satisfy before applying; our RTBS Requirements article covers the eligibility side in full.
Domain 2: Image Production (105 Scored Questions)
This is the domain that decides most outcomes. With 105 of the 185 scored questions, Image Production carries more than half the scored weight, and the specifications break it into three subcategories with their own counts.
| Image Production Subcategory | Scored Questions |
|---|---|
| Basic Principles of Ultrasound | 32 |
| Image Formation | 37 |
| Evaluation and Selection of Representative Images | 36 |
Basic Principles of Ultrasound (32)
This is the physics foundation. Because candidates already hold a supporting credential in sonography or radiography, the exam assumes baseline familiarity, but it tests whether you can apply physics to breast scanning rather than recite definitions.
Physics Topics to Master
- Sound wave properties: frequency, wavelength, period, propagation speed in soft tissue
- Interaction with tissue: attenuation, reflection, refraction, scattering, and acoustic impedance
- Transducer construction, bandwidth, and why high-frequency linear arrays suit superficial breast tissue
- Resolution types (axial, lateral, elevational, temporal) and what controls each
- Doppler principles, including angle dependence and flow-detection settings
- Bioeffects and the ALARA principle
Image Formation (37)
This subcategory asks how the machine turns echoes into the picture, and how your control settings change that picture. It is the most operational of the three: expect questions framed as "the image looks like this; what adjustment fixes it?"
- Gain, time-gain compensation, dynamic range, and focal zone placement
- Depth and field-of-view selection for small superficial structures versus deeper, larger breasts
- Harmonics, compound imaging, and speckle-reduction tools, including their benefits and trade-offs
- Color and power Doppler optimization for suspected vascularity within a mass
- Artifacts: shadowing, enhancement, reverberation, side lobes, and how to tell a true finding from an artifact
- Elastography principles, where they appear in the outline
Evaluation and Selection of Representative Images (36)
Nearly as large as Image Formation, this subcategory tests judgment. You may be shown image or video items and asked to decide which view best documents a finding, whether an image is diagnostic, or what must be repeated.
- Recognizing adequate technique: correct depth, focus, gain, and transducer pressure
- Identifying proper documentation, including labeling, measurements, orientation, and clock-face and distance-from-nipple location
- Choosing the images that best demonstrate a lesion's margins, shape, orientation, and posterior features
- Recognizing when technical errors, such as compression artifact or poor coupling, compromise an image
Because this subcategory leans on visual judgment, text-only review will not prepare you. Work through image-based questions regularly. Our RTBS practice test platform is built for exactly this kind of repetition.
Domain 3: Procedures (64 Scored Questions)
The Procedures domain covers what you actually do at the scanner and around it. At 64 scored questions it is the second-largest domain, and it rewards candidates with strong anatomy and pathology recall.
Procedures: High-Value Content
Think of this domain as three overlapping layers: the exam you perform, the anatomy and pathology you recognize, and the interventional work you support.
- Anatomy: breast layers, ductal and lobular structures, Cooper's ligaments, retromammary space, pectoralis muscle, axillary lymph node regions, and normal sonographic appearances
- Scanning technique: systematic survey patterns, radial and antiradial scanning, patient positioning for different quadrants, axillary and supraclavicular evaluation
- Pathology recognition: simple, complicated, and complex cysts; fibroadenomas; abscesses and mastitis; ductal ectasia; solid masses with suspicious features; and post-surgical changes
- Special populations: pregnancy and lactation, male breast imaging, and breast implants and their complications
- Interventional support: preparation and assistance for image-guided procedures such as aspiration and biopsy, sterile technique, specimen handling, and marker placement
Candidates must also document at least 20 participation experiences in approved elective procedures during the clinical experience window, which is a hint at how seriously the registry weighs interventional familiarity. If you are still logging those, see our requirements guide for how the 200 independently performed examinations and daily logging limits work.
Key Takeaway
Procedures questions often combine anatomy, technique, and pathology in one scenario. Study them as connected workflows: where the lesion sits, how you scan it, how you document it, and what it most likely is.
How Questions Are Delivered
The exam is delivered by computer at a Pearson VUE testing center. Format details that affect your preparation:
- 225 total questions: 185 scored plus 40 unscored pilot items
- 225 minutes of testing time, which is distinct from the 245-minute appointment that includes check-in and tutorial overhead. Do not confuse the two when planning, and disregard any third-party claim of a three-hour exam
- Primarily one-best-answer multiple choice, but the handbook also permits multiple-response, sorting, and image or video items
- Closed-book, with no personal calculator; a test-center-supplied calculator and an on-screen calculator are available
The calculator point is relevant mostly to Image Production, where you may need to work through simple relationships involving frequency, wavelength, or time. Practice using an on-screen calculator rather than assuming you will have your own. Timing is covered further in RTBS Exam Dates.
Scoring, the 75 Standard, and Pass-Rate Context
ARRT reports results on a 1-99 scaled-score system, and a 75 is passing. That is a scaled score, not 75% correct. The raw number of correct answers needed to reach 75 depends on the specific form you receive. ARRT's Standard Setting Report for Breast Sonography, effective September 2026, gives a form-specific raw-score equivalent and a projected pass rate, not a universal cutoff and not an observed 2026 cohort result. For the full explanation, read RTBS Passing Score.
For context on how candidates have performed, ARRT's Annual Exam Report for 2025 lists a first-time pass rate of 78.1% among 146 candidates. Treat that number carefully: that cohort tested before the September 2026 blueprint and passing-standard revision, so it describes the previous exam rather than the current one. Our RTBS Pass Rate article digs into what the data can and cannot tell you.
Eligibility and Fee Mechanics That Shape Your Timeline
Your study calendar should start from eligibility, since you cannot sit for the exam until your application is approved.
Supporting credential
You need a current supporting-category credential: Radiography plus Mammography, or Sonography, or Vascular Sonography. The Sonography and Vascular Sonography supporting credentials may be held through ARRT or ARDMS. The Vascular Sonography route is listed explicitly in the 2026 handbook's supporting-category table.
Education and clinical experience
- ARRT ethics compliance
- 16 structured-education hours within the 24 months before you apply, with at least one credit in each major category
- Within the qualifying 24-month window: independently perform 200 nonsimulated breast examinations and participate in at least 20 approved elective procedures
- Bilateral examinations count as two, no more than nine procedures may be logged per day, scanning must be physically onsite, and each mandatory examination must be presented to the radiologist for final interpretation
Fees and attempts
| Item | Amount |
|---|---|
| Application/exam fee | $225 USD |
| Application/exam fee using an ARDMS supporting credential | $450 USD |
| Reapplication | $200 |
| Annual ARRT registration renewal | $65, regardless of how many ARRT credentials you hold |
You are allowed three examination attempts within three years before requalification is required, which is a three-year window, not three attempts per year. After certification, ordinarily 24 approved CE credits are required each two-year biennium, and credentials earned on or after January 1, 2011 require Continuing Qualifications Requirements (CQR) every ten years. For a full cost picture, see RTBS Certification Cost.
Sequencing Your Prep Around the Blueprint
The single most useful study decision is to let the scored-question counts drive your time. One short, domain-based sequence works well for most candidates already working in imaging.
Image Production: Physics and Image Formation
- Review Basic Principles of Ultrasound (32) and Image Formation (37), which together account for 69 scored questions
- Drill knobology and artifact recognition with image-based items
Image Production: Representative Images
- Practice the 36-question subcategory on evaluating and selecting images
- Focus on documentation conventions and technique errors
Procedures
- Anatomy, scanning technique, pathology patterns, implants, and special populations
- Review interventional support and sterile technique
Patient Care and Mixed Review
- Take the 16-question Patient Care domain in one quick pass
- Complete timed mixed practice sets that mimic the 225-minute format
Front-loading Image Production makes sense because it is both the largest domain and the one where skills compound: physics knowledge supports artifact recognition, which supports image selection. For a broader plan, read the RTBS Study Guide, and keep the RTBS Cheat Sheet handy for last-week review.
Where the Credential Is Used
The Breast Sonography credential is most relevant in settings that perform diagnostic breast ultrasound and image-guided breast procedures: hospital breast centers, outpatient imaging centers, dedicated women's imaging practices, and radiology groups. Employers in these settings often value the postprimary credential as evidence of focused competence beyond a general sonography or mammography background. Because job titles and requirements vary by employer, check current postings rather than assuming any single standard. Our RTBS Jobs article covers the hiring landscape, and the ROI analysis helps you weigh the investment against your own situation.
Frequently Asked Questions
There are three official major examination categories: Patient Care (16 scored questions), Image Production (105), and Procedures (64). Image Production is the largest and is divided into three subcategories.
Most candidates benefit from starting with Image Production because it carries 105 of the 185 scored questions and its physics and image-formation content supports everything else. Patient Care, at 16 scored questions, can be reviewed last.
No. The exam has 225 questions, but only 185 are scored. The other 40 are unscored pilot questions that are indistinguishable from scored ones, so answer every item carefully.
No. A 75 is a scaled score on a 1-99 system. The raw score needed to reach it varies by exam form, so there is no universal number of questions you must answer correctly.
Use it cautiously. That figure comes from 146 candidates in 2025, before the September 2026 blueprint and passing-standard revision. It describes the earlier exam, not the current one.
Mastering these three domains comes down to matching your effort to where the points are: heavy on Image Production, solid on Procedures, and efficient on Patient Care. Pair that approach with realistic, image-based practice at RTBS Exam Prep, and you will be preparing against the blueprint ARRT actually uses.