Current clinical practice guidelines recommend ultrasound (US) every 6 months for surveillance of hepatocellular carcinoma (HCC) in at-risk patients. Despite higher sensitivity, there is uncertainty regarding the role of MRI for HCC surveillance, whether as an add-on or replacement test. Our results indicate that surveillance with standard MRI followed by CT if technically inconclusive provided the highest level of effectiveness. However, CT followed by MRI was more cost-effective than alternative surveillance strategies using a threshold of $50,000 per QALY gained. Further, lower cost of abbreviated MRI will be required to be used as a first-line imaging technique for surveillance.