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ABSTRACT Objective To compare the cost–utility of major intraoperative neuromonitoring (IONM) strategies in thyroidectomy across commercial platforms, and to quantify the impact of continuous IONM (CIONM), automated nerve trend monitoring, postoperative laryngoscopy policy, and technical failure on total episode costs and medicolegal burden. Methods A decision‐analytic cost–utility model of 6000 thyroidectomies was developed using full pathway micro‐costing and QALY outcomes. Strategies included visual identification, intermittent IONM, CIONM, needle‐based IONM, and automated EMG trend monitoring, evaluated in low‐ and high‐utilization settings and stratified by manufacturer. The model incorporated RLN injury costs, routine versus EMG‐guided selective laryngoscopy, and modality‐specific technical failure rates. Results Higher neuromonitoring utilization substantially reduced monitoring costs (€420 to €260 per case), with routine CIONM achieving the lowest values (~€240). Intermittent IONM and CIONM lowered permanent/transient RLN palsy rates from 2.0%/6.0% (visual identification) to 1.2%/4.0% and 0.8%/3.0%, reducing RLN‐related costs from €650 to €430 and €310 per case. Total per‐case costs were €4400 (no monitoring), €4250 (intermittent), and €4100 (CIONM), with CIONM remaining cost‐effective (ICER ≈€8000). Selective EMG‐guided laryngoscopy reduced laryngoscopy costs by up to 65% and improved ICERs. Technical failures increased costs by €90–€110 per case but were mitigable. Manufacturer analyses showed similar per‐case costs (€250–€310) in high‐utilization settings. Conclusion Routine CIONM in high‐volume centres is the most economically favorable strategy, yielding substantial savings and ICERs within accepted thresholds. Selective EMG‐guided laryngoscopy and minimizing technical failures further enhance cost–utility. Automated trend‐monitoring platforms offer a pragmatic, near‐equivalent alternative where full CIONM deployment is limited. Level of Evidence 5.