OBJECTIVES: There has been a marked rise in the incidence of pediatric nephrolithiasis over the past two decades. Although computed tomography (CT) is the gold standard for the diagnosis of nephrolithiasis, efforts to reduce minimize childhood exposure to ionizing radiation remain important. This study aims to assess current imaging trends and rates of surgical intervention for nephrolithiasis at the hospital level. METHODS: A multicenter, cross-sectional analysis was conducted using the Pediatric Health Information System, which included children treated in the emergency department (ED) and diagnosed with nephrolithiasis using ICD 9/10 codes from 2010 to 2021. The analysis involved a hospital-level examination where hospitals were grouped into quartiles based on their rates of CT use. Logistic regression was employed to evaluate the association between hospital-level CT utilization and rates of surgery, while accounting for demographic characteristics and treatments administered including opioids, intravenous fluids, and antibiotics. RESULTS: We analyzed 15,979 ED visits (median age 15 years, 59 % female) across 29 hospitals. There was significant variation in CT utilizations across hospitals (range 13-91 %). Surgery rates at the index visit ranged from 5.3 to 7.5 % and rates of surgery within 6 months ranged from 15.1 to 19.1 % across hospital CT quartiles. After adjusting for demographic characteristics and treatment administered, odds of surgery occurring during the index hospitalization or within 180 days did not differ based upon hospital-level CT utilization (p-trend = 0.19 and 0.26, respectively). CONCLUSIONS: In this hospital-level study of imaging and surgical intervention for pediatric nephrolithiasis, we found no significant association between CT utilization and rates of surgery either during the index visit or within 180 days of the ED visit. These findings suggest there are opportunities to further reduce CT usage in children presenting with nephrolithiasis.