Earnings Call Transcript - LUNG Q4 2020

Operator, Operator

Good afternoon, and welcome to Pulmonx Fourth Quarter and Full Year 2020 Earnings Conference Call. At this time all participants are in a listen-only mode. We will be facilitating a question-and-answer session towards the end of this call. As a reminder, this call is being recorded for replay purposes. I would now like to turn the call over to Brian Johnston from the Gilmartin Group for a few introductory comments. Go ahead.

Brian Johnston, Gilmartin Group

Thanks, Operator. Good afternoon and thank you all for participating in today's call. Joining me from Pulmonx are Glenn French, President and Chief Executive Officer; and Derrick Sung, Chief Financial Officer. Earlier today, Pulmonx released financial results for the quarter and year ended December 31, 2020. A copy of the press release is available on the company's website. Before we begin, I'd like to remind you that management will make statements during this call that include forward-looking statements within the meaning of Federal Securities Laws, which are made pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. Any statements contained in this call that relate to expectations or predictions of future events, results or performance are forward-looking statements. All forward-looking statements, including without limitation, those relating to our operating trends and future financial performance, the impact of COVID-19 on our business and prospects for recovery, expense management, expectations for hiring, growth in our organization, market opportunity, guidance for revenue, gross margin and operating expenses, commercial expansion and the product pipeline development are based on our current estimates and various assumptions. These statements involve material risks and uncertainties that could cause actual results or events to materially differ from those anticipated or implied by these forward-looking statements. Accordingly, you should not place undue reliance on these statements. For a list and description of the risks and uncertainties associated with our business, please refer to the risk factors section of our public filings with the Securities and Exchange Commission, including the quarterly report on Form 10-Q filed with the SEC on November 13, 2020. This conference call contains time-sensitive information and is accurate only as of the live broadcast today, March 2, 2021. Pulmonx Corporation disclaims any intention or obligation except as required by law to update or revise any financial projections or forward-looking statements, whether because of new information, future events or otherwise. With that, I'll turn the call over to Glenn.

Glenn French, CEO

Thanks, Brian. Good afternoon, everybody. Welcome to our Fourth Quarter and Full Year 2020 Earnings Call. Here with me today is Derrick Sung, our Chief Financial Officer. Today, I would like to share a few highlights and contextualize our fourth quarter results before turning to our outlook and strategic priorities for 2021. 2020 was a major milestone year for Pulmonx and I'm very proud of the progress that our entire team has made in building commercial momentum and beginning our journey as a public company. Despite the turmoil caused by the COVID pandemic, we were able to scale our organization, grow our commercial footprint and execute on a public financing that has put us in a strong position to drive our growth initiatives forward once the pandemic subsides. We achieved full-year worldwide revenue of $32.7 million and grew our business in the U.S. by over 50% despite ongoing pressures from the pandemic. The fourth quarter demonstrated that while COVID continues to be a constantly evolving challenge, our business remains resilient. In Q4, we recorded worldwide sales of $9.8 million. The quarter started strong as we recorded our highest month of sales in the company's history in October, but the global resurgence of COVID in the back half of the quarter reversed our momentum, as lockdown measures and increased hospitalizations inhibited our ability to schedule procedures. Despite the transient pressure of COVID, all signals continue to indicate that the underlying clinical need and demand for our Zephyr Valve solution remains strong. And we believe that the COVID-related slowdown in our business will reverse once the pandemic subsides. We are seeing hospitals work with patients who have had their procedures delayed due to COVID by either rescheduling them to a later date or placing them on a waitlist to be scheduled as soon as the hospital allows. Despite the limitations on procedures, interest in Zephyr Valve treatment remains strong as we continue to advance patient screenings through StratX, and the volume of calls to treatment centers and visitors to our website are well above pre-COVID levels. We also continue to see new hospitals starting to use Zephyr Valves, illustrated by the addition of 13 new treatment centers in the U.S. in Q4. Through the full-year 2020, we expanded total U.S. treatment centers well over 50% and ended the year with 148 centers. On the reimbursement front, we continue to make inroads with the Blue Cross Blue Shield Association, securing positive coverage policies from Highmark, the fourth largest Blue Cross Blue Shield plan, which covers approximately five million lives, and the Blue Cross Blue Shield of North Carolina. Our Zephyr Valve procedure was also moved out of the investigational category by Medical Mutual of Ohio, a plan that covers over 1.5 million lives. As a reminder, approximately 75% of our U.S. patient population is covered under Medicare, which typically pays for our medically necessary solution, leaving about 25% of our patients covered by commercial plans. Within this latter category, even commercial payers without positive coverage policies have been approving pre-authorization requests for Zephyr Valves in around 95% of cases. Thus, while we don't expect that reimbursement will be a significant barrier to adoption of our treatment, we do celebrate our commercial policy wins because they reduce the waiting period to treatment for our patients and validate the clinical acceptance of our therapy. Although the COVID-driven pressure and impact on procedure volumes extended through the first two months of this year, we believe the overall outlook for 2021 remains positive given strong and consistent indicators of demand for our Zephyr Valve treatment and the promise of a full vaccine rollout by the second half of this year. As such, we expect full-year 2021 revenue to be in the range of $46 million to $50 million, representing a 41% to 53% growth over 2020. Our business remains uniquely sensitive to the impact of COVID given that our procedure requires a three-night inpatient stay, our pulmonologist customers remain at the forefront of the COVID response, and our patients remain at high risk with their severe respiratory conditions. Accordingly, we expect continued negative impact from COVID through the first half of the year, but we are optimistic that the rollout of the vaccine will alleviate COVID-related pressures in the back half of the year. Looking beyond the near term, we're forging ahead with several initiatives that we believe will fuel our future growth. Chiefly, we intend to focus on furthering the strategic expansion of our U.S. commercial infrastructure to enable us to target more of the approximately 500 high-volume hospitals performing interventional pulmonary procedures. Since our last call, we've added three U.S. territory managers bringing our U.S. territory manager total to 45. Looking forward to the rest of this year, we plan to continue building out our U.S. sales organization by increasing the number of regional directors from six to nine and by expanding the total number of territories to 55 by the end of this year. With this expanded salesforce, we are targeting to open over 50 new treating centers in the U.S. in 2021, bringing our total number of centers to at least 200 by the end of the year. We also expect that the activity levels of our existing centers will meaningfully increase as the pandemic subsides in the back half of the year. We also continue to build our international sales capabilities and intend to add at least five sales reps and two managers outside the United States, bringing the total number of quota carrying reps outside the U.S. to 33 by the end of 2021. These investments in our commercial organization should allow us to better access geographies and increase market development activities as conditions normalize. While we see an incredible opportunity to develop and capture the existing market for severe emphysema patients who are candidates for our Zephyr Valve, we also remain focused on driving future growth by investing in new technologies to broaden the patient population that can be treated with our products. In particular, we are furthering the clinical development of AeriSeal, a polymeric foam that is designed to be delivered via bronchoscope to a targeted region of the lung to treat selected emphysema patients with positive collateral ventilation who are currently not eligible for Zephyr Valves. This group of patients represents approximately 50% of all severe emphysema sufferers who are otherwise eligible for an intervention and thus could significantly increase our addressable market. I am pleased to share that in December, we received designation of AeriSeal as a breakthrough device by the U.S. Food and Drug Administration. While we are still a few years away from potential commercialization of AeriSeal, the breakthrough designation will provide prioritized and potentially accelerated review by the FDA and provides eligibility for Medicare coverage of innovative technology or MCIT. MCIT, a new Medicare coverage pathway, enables receipt of Medicare coverage as early as the same day as FDA market authorization for breakthrough devices and provides coverage for four years. This is particularly relevant as the large majority of our patients are covered by Medicare. In the meantime, we remain focused on moving AeriSeal down the clinical pathway and securing the evidence we need to support coverage in the long term. In summary, despite headwinds through 2020, we grew our U.S. salesforce by over 40%, the number of U.S. treatment sites by over 50% and our U.S. revenues by over 50%. Looking ahead, we believe we are well-positioned operationally and financially to deliver high growth through 2021 and beyond, and to take the next step in establishing ourselves as the global leader and trusted partner in the assessment and treatment of severe lung disease. With that said, I will now turn the call over to Derrick Sung to provide a review of fourth quarter and full-year financial results. Derrick?

Derrick Sung, CFO

Thank you, Glen, and good afternoon, everyone. Total worldwide revenue for the three months ended December 31, 2020 was $9.8 million, a 5% decrease from $10.3 million in the same period of the prior year and a decrease of 8% on a constant currency basis. U.S. revenue in the fourth quarter was $4.9 million, a 4% increase from $4.7 million during the prior year period. The year-over-year increase in U.S. revenue reflects increased sales of Zephyr Valve as we expanded our commercial footprint and drove adoption into new accounts offset by the impact of the COVID pandemic. International revenue was $5 million, a 12% decrease from $5.6 million during the same period last year. On a constant currency basis, international sales decreased by 17% as COVID impacted the ability of hospitals to schedule procedures. Gross margin for the fourth quarter of 2020 was 72% compared to 71% in the prior year period. With the timing of manufacturing related investments to support our growth and the impact of stock-based compensation on labor costs, we expect 2021 gross margins to start out around 70% and to increase modestly throughout the year as we absorb fixed cost overhead across increasing production volumes. Total operating expenses for the fourth quarter of 2020 were $16.4 million, a 41% increase from $11.6 million in the fourth quarter of 2019. Stock-based compensation expense was $2.3 million in the fourth quarter of 2020 and accounted for 45% of the increase in operating expenses from the prior-year period. R&D expenses for the fourth quarter of 2020 were $2.5 million, compared to $1.6 million in the same period of the prior year. Aside from stock-based compensation, the increase was primarily due to an increase in personnel and clinical study-related expenses needed to support our product development and clinical research activities. Sales, general, and administrative expenses for the fourth quarter of 2020 were $14 million, compared to $10 million in the fourth quarter of 2019. Aside from stock-based compensation, the increase was primarily attributable to personnel-related expenses in sales and marketing as we expanded our commercial operations, as well as public company expenses related to the scaling of our general and administrative infrastructure. Looking to 2021 we expect operating expenses to be in the range of $85 million to $90 million, as we continue to build out our commercial operations, invest in our AeriSeal clinical program, and further scale our business. We expect stock-based compensation expense to make up about $9 million of our total operating expenses in 2021. Net loss for the fourth quarter of 2020 was $9.3 million or a loss of $0.27 per share, as compared to a net loss of $4.7 million, or a loss of $2.48 per share for the same period of the prior year. An average weighted share count of 33.9 million shares was used to determine loss per share for the fourth quarter of 2020 and includes shares issued in connection with the closing of our IPO on October 5. We ended the year with $231.6 million in cash and cash equivalents as of December 31, 2020, which includes net proceeds of $201.4 million from our IPO. Turning now to our revenue outlook for 2021. As Glen mentioned, we expect full year revenue to be in the range of $46 million to $50 million, which represents 41% to 53% growth over 2020. This contemplates continued COVID-related pressures through the first half of the year, with the impact being most pronounced in the first quarter. While we do not plan to provide quarterly guidance on a regular basis, given the unique circumstances related to the pandemic, we are forecasting our first quarter revenue to be in the range of $8 million to $8.3 million. This reflects the COVID-driven pressures, which extended through much of February, but also includes our expectation for a stronger March based on current indicators. We expect continued sequential improvement in sales through the remainder of the year, assuming the pandemic further subsides and our expanding base of treatment centers returned to normalized activity levels. With that, I'd like to thank you all for your attention. And we will now open up the call for questions.

Operator, Operator

Your first question comes from David Lewis from Morgan Stanley. You may now ask your question.

Unidentified Analyst, Analyst

Hi, Glen and Derrick. This is actually Cecilia on for David. I wanted to start off just asking about guidance. What you're contemplating in terms of recovery in the US versus ex-US, as well as the trends you've seen play out in those two regions to the first part of this year?

Glenn French, CEO

Actually, the guidance part, I'll ask Derrick to talk about the trends in the various regions, I'd be happy to talk about after that. So Derrick, the first part of the question was the guidance in US and ex-US, how you see that breaking out?

Derrick Sung, CFO

Yes, hi, Cecilia. Our guidance anticipates ongoing pressure from COVID, but it is expected to diminish in the first half of this year, with a recovery projected in the second half. With the introduction of the vaccine and an improving macro outlook, we expect to start moving towards normalcy in the latter part of this year, both in the United States and internationally. This is what we have included in our guidance.

Glenn French, CEO

So we've got just to talk about the trends that we've seen. Obviously, when we last spoke in early November, we were about a month deeper into the European uptick of COVID than we were here. It's really quite remarkable when you look at the shape of the curve and where we were on November 10. So we dove into Europe pretty aggressively and some of the markets have started to pull back out. Places like France and Switzerland have come out more strongly; France was hit by the virus at least a month before us here. But each of the countries is pulling out differently. Germany is slow to pull out; they have actually installed a mechanism by which they want to make sure that they have at least 25% of their ICU capacity in reserve in the event there's another wave, which is an unheard of level of capacity, for example, in the United States, where even in the worst-case scenario, you're going to have probably two-thirds of your beds full of just standard ICU patients, and a third of them full of COVID patients. And to keep 25% just open is going to take a little time to get back and going in Germany. In the United States, it was really quite remarkable. We had assumed we saw this wave coming, we saw what was happening in Europe, we knew that it was going to happen here in the U.S. And so we anticipated the step down October to November to December, and we had assumed that we would see a step up that would look very much like the step down specifically in January, February, and March. And what happened was, we bottomed out and it carried into February, basically the first couple of weeks of February. So that's the shape of the curve; it was a little less V-shaped and a little more U-shaped. And we have some very encouraging more recent information as it relates to pulling out of that. And it looks extraordinarily familiar to the last two times we got hit with waves here in the United States.

Unidentified Analyst, Analyst

Okay, thank you. That's helpful. If I could also ask on your backlog, what you've seen in terms of dynamics trends versus late summer in the US, as well as if you could provide some additional color in terms of what you're seeing on StratX trends recently? Thank you.

Glenn French, CEO

Regarding backlogs, focusing on the United States, which constitutes about 50% of our business, we have an immediate backlog. The situation in other countries is similar, influenced by how quickly they shut down and reopened due to COVID. The backlog arises naturally because when procedures are halted, anyone scheduled has either their dates pushed out or is placed on a waiting list for when hospitals resume operations. Additionally, we have been processing StratX scans, leading to an accumulation of patients identified as StratX Greenlight candidates. This means that their CT scan data has been evaluated, making them eligible for procedures, often involving Chartis at the outset, followed by valve placements. We have built up a backlog, which we will start to address as accounts reopen. Typically, the first patients treated in these accounts after reopening are those who had their procedures rescheduled or postponed.

Operator, Operator

Your next question comes from the line of Bob Hopkins from Bank of America. Your line is now open.

Robert Hopkins, Analyst

Thanks and good afternoon. You said you are at 148 centers, I think, right now. Just curious, how many of those are up and running right now and doing procedures?

Glenn French, CEO

That's a good question, and I'll answer it shortly. First, I need to correct something from my earlier comments. I mentioned North Carolina, but I meant North Dakota regarding our success with Blue Cross Blue Shield. Bob, your question about active accounts is insightful. Previously, we reported active accounts quarterly, and during the pre-COVID phase, about 70% of our accounts were considered active within a 90-day period based on the procedures they completed and products they purchased. The COVID situation has been unpredictable, so on this occasion, I’ll provide some monthly data to illustrate how things have fluctuated throughout the year. Initially, in April, we saw our active accounts drop dramatically to just 4%. We hadn’t reached that low since then, but by July, we managed to increase to around 60% active accounts. Nevertheless, there was a constant impact from COVID, which caused us to dip again in December to roughly 30%. We anticipated a similar trend in January, which turned out to be true, with active accounts at 32% for both December and January. We expected a significant recovery in February, but the average remained around 33%. In the latter half of February, we started to notice a revival; while initially, we had only 32% active accounts, revenues surged, increasing about 30% in that period. The scheduled cases have also risen, indicating a promising trend. This pattern of recovery has been evident during the last two waves, showing a strong upward trajectory over the last few weeks.

Robert Hopkins, Analyst

Thank you for that, it's very helpful. It seems like you're almost back to levels that suggest if you maintain the run rate from late February to early March, you should reach your guidance for this year. I may be slightly off since specific revenue numbers for the second half and the first half of February were not provided. However, it appears to be a solid recovery. So, am I generally correct in this assessment? Additionally, can you tell me how many active centers we have right now and what that percentage is today? I apologize if I missed that in your earlier response.

Glenn French, CEO

In February, the number of active centers was 33%. We are working to revive those centers. If the normal level is 70%, we anticipate roughly doubling the number of active centers to reach that target. Additionally, we previously mentioned that there are two aspects to this situation. One is the percentage of our accounts that are active, which I shared earlier, and I can confirm that they have all declined due to COVID. There isn't any other factor at play. The second aspect is the established accounts, which were previously averaging about seven procedures per quarter once operational. Currently, these established accounts are averaging about four procedures per quarter. Therefore, our focus is on not only reopening these accounts but also returning them to pre-COVID procedure levels. We started seeing an acceleration in existing accounts in late February, and we also had a significant new account, the Kaiser account, which just conducted their first case today. We expect to see more existing accounts come back online and additional new accounts starting up.

Operator, Operator

Next question is from Frederick Wise with Stifel. Your line is now open.

Frederick Wise, Analyst

Good afternoon, gentlemen. Glen, could you provide more details about the 65% to 70% of accounts that are not currently active? I'm curious to know your engagement with them, what feedback they are giving, and what it would take to reactivate their accounts. What do you perceive as the obstacles? Please share your thoughts on the inactive dock and center.

Glenn French, CEO

Yes, we are very attentive to ICU capacity and usage. Reflecting on the recent trends, we have seen a significant increase in cases, reaching a peak, and now we are nearly back to the same level as our last discussion. However, the ICU situation has a delayed response. Hospitals are working to ensure they have the necessary ICU capacity before ramping up their operations again. One key indicator of activity is revenue. I've noted that approximately 70% of our business is linked to trunk stocks, and revenue should mirror case trends. For instance, in the latter half of February, our revenues were 80% higher than in the first half, primarily from restocking accounts and preparing for upcoming procedures. Other important metrics include the increasing trend in StratX accumulations since the start of the year, more inbound calls to our treatment centers, and a rise in web traffic related to procedures. We have also managed to add 13 new accounts in the fourth quarter, despite the challenging circumstances, and we are optimistic about case volume moving forward.

Frederick Wise, Analyst

Great. I'm not sure if this question is relevant or can be answered since it's still early days, but out of curiosity, Glen, you keep mentioning that StratX is growing. I assume it must be growing more than implants. Is there a ratio of StratX to implants that you can share? I would expect it to typically be higher than the implant rates. Is it something like one and a half times the normal rate?

Glenn French, CEO

It's challenging to provide that data at the moment due to the impact of COVID and the inconsistent nature of procedures. The situation makes it difficult to share that information. We are experiencing delays, and although we have developed algorithms to analyze the situation, COVID has significantly affected our progress. We encountered three significant waves of COVID in 2021, which disrupted our operations. When we look at the timelines for the StratX scan and treatment, the data is not straightforward. The delays we faced mean that determining whether the typical timeframe between a StratX scan and treatment is seven months is uncertain. While we are actively seeking insights, we need clearer conditions to gather reliable data. I can't confirm whether the trend is upward at this point. Previously, I expressed concern about the future, but I now feel much more optimistic as we appear to be moving past these challenges. I recently heard that everyone is expected to be vaccinated by the end of May, although it remains uncertain if that will happen. Overall, I believe we are moving in a positive direction, and there are many signs indicating our business is aligning favorably.

Frederick Wise, Analyst

Great, it's wonderful to hear. Two last quick ones, I'll ask them at the same time, just so Derrick doesn't feel left out. I know you’re anxious to give us gross margin guidance for 2021. I say to myself, okay, the fourth quarter was a more pressured quarter than you might have expected, you stole my gross margin number, why wouldn't 2021 be at that fourth quarter rate, if not better, but why wouldn’t it be better given higher volume? And my last I'm just curious, you didn't talk about weather Glen, to what extent did weather have an impact on your January, February volumes? Maybe not at all; I don't know. But thank you very much.

Glenn French, CEO

I'll take the last question first. As staggering as that snowstorm was, and I'm sure we lost a few cases as a result, all my salesforce is talking about is COVID restarts and so forth. So I think it got muted a little bit by the impact of COVID restarts. But I'm sure we probably postponed some number of cases and various different locations. Derrick, gross margin?

Derrick Sung, CFO

Yes, that's a great question, Rick. So when we think about gross margins for 2021, there's a couple of important dynamics to consider. So first off, we were very happy to see our gross margin at 72%, which I think is one of the highest levels that we've ever seen in this last fourth quarter of 2020. Moving into 2021, there are two dynamics to factor in. One is that we're seeing a significant increase in stock-based compensation expense. So that clearly flows through the OpEx line, as I mentioned, and we're expecting $9 million of the OpEx guidance that I provided to you to be accounted for by this non-cash charge. Stock-based compensation also flows into our COGS through an increase in labor costs. And that gets capitalized into inventory, and then comes through the P&L as we sell our inventory. So stock-based compensation-related cost to labor, dragged down our gross margins by about 1% next year. And then on top of that, we do have a couple of manufacturing-related initiatives and investments associated with helping to automate our supply chain and helping to mitigate risks through second sourcing, if you will. And some of those expenses also hit our COGS line next year. So that's the reason why we think we'll start out at around 70% versus the 72% that we saw last quarter, but we do then expect them to move up our gross margins steadily by a point or so probably throughout the year, as we continue to drive overhead absorption through our increased production volumes.

Operator, Operator

Next question is from Lawrence Biegelsen from Wells Fargo. You may ask your question.

Lawrence Biegelsen, Analyst

Good afternoon. Thanks for taking the question, just a few for me here. Derrick, on OpEx, I think even when you adjust for stock-based comp; the guidance was a little bit higher than we were modeling. So could you give us an apples-to-apples number, the $85 million to $94 million for 2021 versus what it was ex-stock-based comp adjusting for that compared to 2020? And just a color on where the incremental spending is going? And I had a couple follow-ups.

Derrick Sung, CFO

Yes, so stock-based comp in 2021, again, as I mentioned, I think that's going to be close to $10 million, call it $9 million, or so in contribution. So, absent that stock-based comp, you're talking $10 million lower. So $70 million, $75 million or so to $80 million. And in terms of the stock-based compensation in 2020, it was relatively low, absent Q4, where we did see a significant contribution primarily from the ESPP program. And, of course, this is all related to the very rapid appreciation of our stock price. So again, I would take out about $9 million from our 2021 OpEx, and that's what it would have been without this non-cash charge. Now, in terms of where the office spend is going to go, I would think about a few million dollars step-up sequentially between the $16.4 million that we did in Q4 and what we think we'll do in Q1, and that initial step up is, again, public company costs and incremental stock-based comp charges. And then, I would expect to see a continued slight increase in OpEx through the remaining three quarters of the year. And that OpEx is primarily driven by an increase in personnel-related expenses, much of which is related to expansion of our commercial organization or commercial infrastructure, as well as some G&A. And then, on the R&D front, spend toward our clinical study costs associated with AeriSeal, again, increasing through the back part of the year, is a major driver for that expense.

Lawrence Biegelsen, Analyst

That's very helpful. And just two last ones for me here. What are the next steps in AeriSeal? Congratulations on the breakthrough status. But what's the path forward here? And just lastly, Glen, any update on Japan? Thanks for taking the questions.

Glenn French, CEO

Yes. So with regard to AeriSeal, as we've talked about before, we're executing a study in Europe. When we last spoke, I think we had maybe an ethics approval, we've got a number of them now, we've got three sites that have been activated. We've enrolled a few patients already. So we're off and running on that trial. So that's where we are. We're also planning on submitting an IDE in the US later this year, specific to AeriSeal. So we're marching along, that's something that we are very interested and excited about. But it's off on the horizon, perhaps setting best case US market entry at the end of 2024, almost certainly 2025, certainly expect to be outside the U.S. before then, but probably sometime during 2024. So those are things that are out in front of us, and we're working hard on. With regard to Japan, that too is something that we're very focused on. I think we're on schedule, as it relates to what we talked about probably the last time, which is to say that we are planning on submitting our application to PMDA later on this year, and we see ourselves commercial sometime probably later in 2023.

Operator, Operator

Your last question is from William Plovanic. Your line is now open.

William Plovanic, Analyst

Hi, thanks. Just a question on clarification, Glen, you mentioned that you're seeing high volumes at the centers that are active. And my only question really coming out of this is, are you seeing patients that are transferring from one center to another in order to get a procedure completed? Or are these your existing customers just becoming more active?

Glenn French, CEO

It is certainly more about the latter than the former. We have observed patients moving from one center to another, often from a facility that isn’t performing procedures to a treatment center. This was the case today at Kaiser, where patients transferred from one Kaiser location to another to undergo the procedure. Such movements occur occasionally. In military hospitals, this often happens as well, where patients go to local hospitals that are conducting the procedure. Regarding the higher volumes in existing centers, it’s possible that my assessment of the number of accounts isn't quite aligned with my understanding of revenues and case volume. However, my indications suggest that existing accounts are performing more procedures, which seems logical. I believe they feel more confident moving forward, believing that there won’t be another wave of challenges, allowing them to reduce some patients from their waiting lists.

William Plovanic, Analyst

Yes. Your commentary that the average four per quarter versus seven, is that for the active centers or all the centers? Because what I'm trying to get at is, are you exceeding that seven if those active centers are doing eight or nine, and so when we do get the opening back up, what can that translate to?

Glenn French, CEO

Yes, these numbers are probably relatively steady state numbers. And what happens when you come out of here, as you get these kinds of post-wave, this being the third, I expect that those are going to be lumpy. And we'll have to see that over time, I expect that we will get back up to seven. During this re-emergence, I wouldn't be surprised that if people pull some number off of a waiting list, that they may go above what they would normally do when they get back to steady state. So I don't think I have a really clean answer to your question.

Operator, Operator

I'll turn the call back over to Glen, for closing statement.

Glenn French, CEO

Great, well, I really have a closing statement, but I really appreciate everybody's interest and ongoing support. And we're very excited about what's out ahead. We've navigated through some pretty challenging situations and are very pleased with the fundamentals that we see aligned as we move forward. So thank you very much.

Operator, Operator

Ladies and gentlemen, that concludes today's conference call. Thank you for participating. You may now disconnect.