Parathyroid localization is predicated on the definitive confirmation of both the biochemical diagnosis and surgical indication in primary hyperparathyroidism (PHPT), with imaging providing a dynamic, albeit ancillary, adjunct to guide the surgeon’s operative plan. For focused parathyroidectomies, localization is mandatory to facilitate the targeted approach. Ultrasound is the preferred first-line modality in both the unexplored and re-operative patient. Surgeon sonographic confirmation is sufficient to proceed with a focused approach, while negative localization should prompt a bilateral exploration for the unexplored patient. Two concordant modalities confirming a well-localized target should be obtained in the remedial setting to afford a focused approach to mitigate the elevated surgical risks. Adjuncts to ultrasound include scintigraphy, 4D CT, selective venous sampling, and at select institutions FCH-PET/CT/MRI. Nonlocalized remedial patients or those with prohibitive surgical risks should be discussed in a multidisciplinary forum with consideration for medical management.