Surgical complications following pediatric liver transplantation are common and expensive. We examined the incremental costs of surgical complications and determined who pays for these complications (center or payer). We reviewed the records of 36 pediatric liver transplant patients aged <or=12 yr transplanted between July 1, 2002 and December 31, 2005. The association of recipient and financial data points was assessed. On univariate analysis, total hospital costs were significantly increased in patients with ACR, PNF, HAT, biliary complications, and ARF. Reimbursement by the payer was significantly increased in patients with PNF, HAT, biliary complications, and ARF. Hospital profits were significantly decreased in recipients with ACR and pneumonia. Multiple linear regression models (controlling for recipient factors) revealed that ARF and HAT were independently associated with a significant increase in median hospital costs (incremental costs of $238,990 and $125,650, respectively). ARF and HAT were also independently associated with a significant increase in median reimbursements (incremental costs of $231,611 and $125,287, respectively). No complications were independently associated with hospital margins. All parties (patient and families, physician, payer, and medical center) should benefit from quality improvement efforts, with payers having the largest financial interest.