Introduction Excessive alcohol use cost the US $223.5 billion in 2006. Given economic shifts in the US since 2006, more-current estimates are needed to help inform the planning of prevention strategies. Methods From March 2012 to March 2014, the 26 cost components used to assess the cost of excessive drinking in 2006 were projected to 2010 based on incidence (eg, change in number of alcohol-attributable deaths) and price (eg, inflation rate in cost of medical care). The total cost, cost to government, and costs for binge drinking, underage drinking, and drinking while pregnant were estimated for the US for 2010 and allocated to states. Results Excessive drinking cost the US $249.0 billion in 2010, or about $2.05 per drink. Government paid for $100.7 billion (40.4%) of these costs. Binge drinking accounted for $191.1 billion (76.7%) of costs; underage drinking $24.3 billion (9.7%) of costs; and drinking while pregnant $5.5 billion (2.2%) of costs. The median cost per state was $3.5 billion. Binge drinking was responsible for> 70% of these costs in all states, and> 40% of the binge drinking–related costs were paid by government. Conclusions Excessive drinking cost the nation almost $250 billion in 2010. Two of every $5 of the total cost was paid by government, and three quarters of the costs were due to binge drinking. Several evidence-based strategies can help reduce excessive drinking and related costs, including increasing alcohol excise taxes, limiting alcohol outlet density, and commercial host liability.