- Specialty MEP density — operatories, commercial kitchens, lab gas, sterile/negative-pressure HVAC zoning.
- Imaging / shielding — lead-lined rooms (X-ray, CT, cone-beam) add cost and structural needs.
- Finish level — premium materials, custom millwork, amenity spaces.
- Structural choices — steel vs. tilt-up vs. CMU can swing cost 10–25%; foundation type can swing ~20% on bad soils.
- Site conditions — poor soils, demolition, utility extension, detention/drainage, grading.
- Speed — compressed schedules (overtime, premium procurement) cost more.
- Sustainability — LEED Silver adds ~1–3%, LEED Gold ~3–5% (also unlocks tenant/institutional demand).
- Escalation — building later costs more in an inflationary market; locking material orders early protects budget.
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