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**Background:** The costs of transporting end-stage renal disease (ESRD) patients to dialysis centers are high and growing rapidly. Research has suggested that substantial cost savings could be achieved if medically appropriate transport was made available and covered by Medicare.**Objectives:** To estimate US dialysis transportation costs from a purchaser’s perspective, and to estimate cost savings that could be achieved if less expensive means of transport were utilized.**Methods:** Costs were estimated using an actuarial model. Travel distance estimates were calculated using GIS software from patient ZIP codes and dialysis facility addresses. Cost and utilization estimates were derived from fee schedules, government reports, transportation websites and peer-reviewed literature.**Results:** The estimated annual cost of dialysis transportation in the United States is $3.0 billion, half of which is for ambulances. Most other costs are due to transport via ambulettes, wheelchair vans and taxis. Approximately 5% of costs incurred are for private vehicle or public transportation use. If ambulance use dropped to 1% of trips from the current 5%, costs could be reduced by one-third.**Conclusions:** Decision-makers should consider policies to reduce ambulance use, while providing appropriate levels of care.

High Costs of Dialysis Transportation in the United States: Exploring Approaches to a More Cost-effective Delivery System