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s were associated with higher testing utilization rates. The aim of this study was to explore state-level relationships between the incidence and payout amounts for medical malpractice claims and Medicare imaging utilization and spending across the United States. Using claims data from a 5% sample of Medicare beneficiaries for 2004 to 2016, annual state population-adjusted rates of imaging utilization and spending were calculated. Using National Practitioner Data Bank files, all paid physician malpractice claims were identified, and lagge