OBJECTIVES: To compare the clinical and cost consequences of Gadoxetic Acid-enhanced magnetic resonance imaging (PV-MRI) to extracellular contrast media-enhanced MRI (ECCM-MRI) and Multidetector Computed Tomography (MD-CT) in patients with suspected hepatocellular carcinoma (HCC) in South Korea and Thailand METHODS: The clinical pathway of patients with suspected HCC from the initial imaging procedure (PV-MRI, ECCM-MRI or MD-CT) to the confirmed treatment decision was presented in an economic decision-tree model. The model compared payer relevant costs of the three diagnostic procedures as first line imaging for suspected HCC and the subsequent costs to reach a confirmed treatment decision. The probabilities and resource consumptions were estimated and validated by clinical experts through a Delphi panel process. Costs for diagnostic and treatment options were derived from published sources. RESULTS: Using PV-MRI as first imaging procedure in patients with suspected HCC evokes total cost of US$ 3,098/patient in Korea. This is 0.1% higher than the costs for MD-CT (US$ 3,094/patient), but 9.9% lower (US$ 306) than the costs of ECCM-MRI (US$ 3,405/patient). In Thailand, PV-MRI (US$ 702/patient) is the least costly alternative compared to ECCM-MRI (US$ 930/patient) and MDCT (US$ 872/patient) and leads to cost savings of US$ 228 US$and US$ 170, respectively. The higher acquisition cost of PV-MRI are more than compensated by the cost saving achieved through the reduced need for confirmatory imaging procedures and the reduced need for changes in the surgical protocol during resection. CONCLUSIONS: Using PV-MRI compared to ECCM-MRI and MD-CT for the first imaging in patients with suspected HCC leads to relevant cost savings for the statutory health insurance in both countries. The impact on health outcomes (e.g. mortality, quality of life) and total cost needs to be shown in an extended study approach.