OBJECTIVES: To compare the total cost of hepatocyte-specific Gd-EOB-DTPA enhanced MRI (PV-MRI) to extracellular contrast media-enhanced MRI (ECCM-MRI) and multidetector CT (MDCT) as initial imaging procedures among patients with suspected hepatocellular carcinoma (HCC) from China healthcare perspective. METHODS: A decision-tree model based on the Chinese clinical guidelines and validated by clinical experts was used to compare the diagnostic effectiveness of alternative initial imaging procedures to optimize therapeutic decisions for suspected HCC patients. Patients with suspected  HCC as identified by ultrasound and alpha fetoprotein (AFP) levels entered the model. The three initial imaging methods were compared based on HCC prevalence in the included population, diagnostic accuracy (sensitivity and specificity) of the imaging alternatives, transition probabilities and costs as derived from published literature or expert opinion from 4 leading tertiary hospitals in China. One- and two way sensitivity analyses explored the impact of input variables such as diagnostic cost, HCC prevalence and cost of therapy. RESULTS: The base case HCC prevalence rate was 47.0%. Confirmatory additional imaging was necessary for 34.0% of patients after initial CT imaging, 22.5% after initial ECCM-MRI and 0% after initial PV-MRI. False positive (patients having unnecessary surgery) rate was 2.7% for PV-MRI, 4.6% for MDCT and 9.6% for ECCM-MRI. The false negative (missed HCC diagnosis) rate was 3.9% for PV-MRI, 12.5% for MDCT and 9.6% for ECCM-MRI. Total cost per patient after initial PV-MRI (CNY 30,357) was slightly lower than MDCT (CNY 30,653) and ECCM-MRI (CNY 31,892). The sensitivity analyses revealed that HCC prevalence in the at-risk-population had the highest impact on the cost comparison of the 3 diagnostic procedures. CONCLUSIONS: Due to higher diagnostic precision, the total cost of making a therapeutic decision with Gd-EOB-DTPA-MRI as primary diagnostic imaging method in China is unlikely to be higher than with ECCM-MRI and MDCT.