Good afternoon, and welcome to PROCEPT BioRobotics' Q2 earnings conference call. At this time, all participants are in listen-only mode. We'll be facilitating a question-and-answer session towards the end of today's call. As a reminder, this call is being recorded for replay purposes. I would now like to turn the call over to Matt Bacso from the Gilmartin Group for a few introductory comments.
Thanks, operator. Good afternoon, and thank you for participating in today's call. Joining me from PROCEPT BioRobotics are Reza Zadno, CEO, and Kevin Waters, CFO. Earlier today, PROCEPT released financial results for the quarter ending June 30, 2022. 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 related to our sales and operating trends and future financial performance, expense management, expectations for hiring or growth, market opportunity, revenue guidance, commercial expansion, and future product development and approvals, are based upon 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 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 most recent annual report on Form 10-K filed with the Securities and Exchange Commission on March 22, 2022, and available on EDGAR and in our other public reports filed periodically with the SEC.
This conference call contains time-sensitive information and is accurate only as of the live broadcast on August 4th, 2022. PROCEPT BioRobotics 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 will now turn the call over to Reza.
Thanks, Matt. Good afternoon, and thank you for joining us. For today's call, I will provide opening comments and a business update, followed by Kevin, who will provide additional details regarding our financial performance and updated 2022 financial guidance before opening the call to Q&A. starting with our quarterly revenue results. Total revenue for the Q2 of 2022 was $16.7 million, representing growth of 97% compared to the Q2 of 2021, and 18% sequential growth compared to the first quarter of 2022. U.S. revenue for the quarter was $14.8 million, representing growth of 126% compared to the prior year period.
In the Q2, we sold 23 AquaBeam Robotic Systems, generating total U.S. revenue of $8.5 million, representing growth of 79% compared to the Q2 of 2021. AquaBeam Robotic System continues to be primarily driven by sales at high volume BPH hospitals. U.S. handpiece and consumable revenue was $5.7 million, representing growth of approximately 246% compared to the Q2 of 2021. Handpiece growth was driven by an increase in the installed date of AquaBeam Robotic System, which has grown 56% from the Q2 of 2021. Additionally, we have seen an increase in utilization from our install base as measured by handpiece sold per account. Utilization per account increased approximately 90% compared to the Q2 of 2021.
We believe the combination of releasing positive long-term clinical data, increased private payer coverage, and outstanding real-world patient outcome continues to drive surgeon interest and hospital adoption of AquaBeam Robotic System. before providing a business update, let me briefly address the current macro environment, specifically supply chain and hospital capital equipment spending. First, I want to highlight we have not experienced material product constraints in our ability to meet customer demand, nor has inflation been a concerning issue to date. While we continue to take the challenges associated with this global supply chain seriously, we have been able to navigate this disruption period well, having successfully increased inventory levels for key components. As we progress through the year, we are focused on ensuring we can supply our customers with what they need in a way that is high quality and timely.
As it pertains to hospital capital spending, we believe we are uniquely positioned for continued momentum around our AquaBeam Robotic System sales in the back half of the year due to multitude of positive factors around our technology and our early stage of market penetration. First, BPH is the number one reason men visit the urologist, with many men seeking durable surgical treatment options at high volume hospitals. Additionally, many of these men forgo treatment due to the inferior safety profile of current surgical alternatives. With a growing and increasing educated patient population, hospital systems are motivated to invest in cutting-edge technologies to ensure they stay competitive and not lose patients to other area hospitals. We believe our AquaBeam Robotic System allows hospitals to offer a cutting-edge technology in the BPH surgical space.
Next, we exited the Q2 of 2022 with an installed base of 114 U.S. systems. With approximately 2,700 total hospitals performing surgeries, of which 860 are high-volume targets, we are still very early in our adoption curve with a long runway in front of us. It is also an important reminder that the high-volume BPH hospitals we target are well-funded with ample liquidity, which we believe mitigates some of the risks associated with an uncertain macro environment. Additionally, since the approval of purchase of AquaBeam Robotic System is typically managed at the local hospital level and can routinely be authorized by the hospital CEO and CFO, this streamlines the more complex approval process that may be required for other higher-priced capital equipment.
Lastly, given AquaBeam's unique ability to treat all shapes and sizes of prostates, hospitals are now more than ever standardizing their BPH surgical protocol. This standardization, along with our increased insurance coverage, makes Aquablation a logical choice. In summary, we continue to monitor all aspects of the macro environment and its impact on our business. We would not be increasing our revenue guidance, which Kevin will provide details on shortly, if we felt pressure associated with the capital equipment environment. Now turning to quarterly business updates, starting with our commercial organization. We have successfully hired a highly efficient commercial team of experienced medical device sales professionals. We implemented an effective training and onboarding program to put us in position to execute our 2022 commercial growth plan.
While we approximately doubled our field-based commercial team at the end of 2021, the number of reps has been relatively unchanged for six months. Given the commercial momentum, excellent real-world clinical outcome, and increased demand our technology has been able to generate, we plan to meaningfully expand our field-based commercial team in the third and fourth quarter of 2022 to further penetrate the market and expand our sales presence in the U.S.. This increase is captured in our updated operating expense guidance. Even with a tight labor market, we continue to see strong interest from high-quality candidates, which gives us additional confidence in meeting our hiring and growth objectives heading into 2023. Next, I would like to comment on utilization and procedure trends which we have seen in the last 12 months.
We continue to believe the majority of Aquablation procedure volumes are converted TURP cases, which is the most commonly performed surgical procedure for BPH. We also believe we are taking resective procedures from other modalities like simple prostatectomies and laser procedures of the prostate. On hospital utilization, we are seeing meaningful annual increases in utilization from our customers. We believe based on our clinical data, the increase in utilization is attributable to the following factors. Given the predictability, reproducibility, and low learning curve associated with the AquaBeam Robotic System, we are generally seeing an increasing number of surgeons using our system each quarter at our accounts. As a result, we believe an increasing number of accounts are beginning to standardize their resective procedure protocol in favor of Aquablation therapy.
Additionally, since our clinical data support outcomes that are independent of prostate size and shape, surgeons are using Aquablation therapy in a broader range of prostate sizes. Specifically, when analyzing patient data from January 2021 to June 2022, we found the most prevalent size range treated fell between 60-80 ml . Given the size range of prostates treated over the last 18 months, we believe surgeons are beginning to standardize their procedures to Aquablation given the limitation of surgical alternatives. Turning to clinical updates. In May, we announced four-year WATER II study data at the American Urological Association conference in New Orleans. As a reminder, WATER II was a prospective FDA study with an objective performance criterion for both efficacy and safety in large prostates ranging in size from 80-150 ml.
The four-year data were consistent with the previously reported primary endpoints with no change to safety results. The efficacy result as measured by change in IPSS and Qmax also consistent at four years. Lastly, durability remains strong with only 3% of patients requiring surgical retreatment at any time up to year four. More recently, in early July, we attended the European Association of Urology conference in Amsterdam. This was the first in-person European event since the pandemic and was well attended with more than 7,000 registrants. A key talking point among surgeons and key opinion leaders was our five-year WATER data published in February 2022. As a reminder, our five-year WATER data are the only prospective randomized double-blind multi-center FDA clinical study comparing the safety and efficacy of Aquablation therapy to TURP.
The study proves Aquablation superior safety due to low irreversible complications and superior symptom relief for prostates ranging from 50-80 ml. Aquablation at five years exhibited durability that was two times lower risk for retreatment due to recurrent BPH symptoms when compared to TURP. This is measured by patients going back to meds or requiring surgical retreatment, which is represented by an approximate 1% annual retreatment rate. In Europe specifically, surgeons are enthusiastic about strong clinical data, which is driving them to learn more about Aquablation therapy. Given this backdrop, we believe five-year WATER and four-year WATER II data will be a significant differentiator for our customers when choosing to replace their historical BPH surgical modalities with Aquablation. Lastly, touching on recent payer coverage policy updates. In the Q2, we received numerous insurance coverage updates adding to the already strong list of payers for Aquablation therapy.
In April, Aetna published its updated policy noting Aquablation therapy as a covered surgical alternative for BPH, providing coverage for their roughly 21 million commercial members in the U.S.. Additionally, in the Q2, numerous Blue Cross Blue Shield Association healthcare plans also issued positive coverage as well as Medical Mutual. In aggregate, these policies, along with existing coverage policies, provide coverage for approximately 180 million members. As it relates to the impact of coverage on our business, there is both a long-term benefit and a short-term benefit. The obvious long-term benefit is increased utilization, which will take time as we penetrate the surgical market. The more important short-term benefit is the increased value proposition of our technology and the lowering of barriers to sell capital equipment to targeted high-volume BPH hospitals.
Additionally, in mid-July, CMS published its 2022 proposed rule for Hospital Outpatient Prospective Payment System. The Level 6 APC code for Aquablation has a proposed payment that would provide the hospital approximately $8,700 for each Aquablation procedure, which is an approximate 3.5% increase over the 2022 rates, and in line with our expectations. The final rule is estimated to be published in November. In summary, we are pleased with our performance year-to-date and continue to execute our strategic growth plan of penetrating high-volume hospitals, increasing utilization by treating the full range of prostate sizes and shapes, and expanding private payer coverage. Given this positive momentum and the announcement of our long-term clinical data highlighting durability, we believe Aquablation therapy will truly revolutionize the treatment of BPH. With that, I will turn the call over to Kevin.
Thanks, Reza. As Reza highlighted, our revenue for the Q2 of 2022 was $16.7 million, representing growth of 97% compared to the Q2 of 2021. The increase was primarily driven by U.S. revenues, including both system sales to new hospital customers and increased handpiece revenue. In the Q2, we generated total U.S. system revenue of $8.5 million, representing growth of 79% compared to the Q2 of 2021. In the U.S., we sold 23 AquaBeam Robotic Systems with an average selling price of approximately $370,000. Average selling price increased approximately 6% sequentially and 10% compared to the prior year Q2. Our ending Q2 U.S. install base was 114 AquaBeam Robotic Systems.
Q2 2022 U.S. handpiece and consumable revenue was $5.7 million, representing growth of approximately 246% compared to the Q2 of 2021. Handpiece average selling prices in the quarter were approximately $3,000. We shipped approximately 1,740 handpieces in the U.S. in the Q2, representing annual unit growth of 176%. International revenue for the Q2 was $1.9 million, which was roughly flat compared to the prior year period and increased 15% sequentially. International revenues in the Q2 of 2021 benefited from a meaningful number of rescheduled procedures and the deferral of capital sales from a severely impacted first quarter of 2021 due to COVID. Our strategy in Europe continues to be to increase brand awareness and market development activities.
On a year-to-date basis, international revenue has increased approximately 23% from prior year and is in line with our expectations. Gross margin for the Q2 of 2022 was approximately 51%, an increase from 42% in the Q2 of 2021. The increase in gross margin was driven by a variety of factors, including higher U.S. sales, increased average selling prices, and higher production volume as we spread the fixed portion of manufacturing overhead costs across a larger number of units produced. Total operating expenses in the Q2 of 2022 were $26.4 million compared to $16.8 million in the first quarter of 2022.
The increase was primarily driven by increased compensation, general and administrative expenses, and the sales organization, and increased expenses associated with. Net loss was $19.2 million for the Q2 of 2022, compared to $14.6 million in the same period of the prior year. Adjusted EBITDA was a loss of $14.6 million compared to a loss of $11.6 million in the Q2 of 2021. Our cash and cash equivalents balance as of June 30 was $270 million, while our long-term borrowings totaled $50 million. We believe our strong balance sheet will provide the liquidity and capital resources needed to support and grow our current business. Moving to our financial guidance.
Given our strong start to the year and continued underlying momentum in the business, we are increasing our full-year 2022 total revenue guidance to be in the range of $66 million-$68 million. Although utilization trends in the third and fourth quarter are expected to be down relative to first half levels, our updated revenue guidance assumes sequential growth in handpiece sales per quarter. As explained previously, as our install base increases throughout the year, this will provide a natural headwind to average utilization rate as new accounts are added. Regarding handpiece average selling prices, we expect pricing to be in the $3,000 range for the remainder of 2022, which is in line with year-to-da te actuals. Turning to AquaBeam Robotic System sales.
We continue to expect modest sequential increases to the number of systems sold throughout the year, with average selling prices now expected to be in the range of $360,000 for the second half of 2022. Lastly, on the revenues, we expect 2022 international revenue growth of approximately 30% compared to 2021. Moving down the income statement. We now expect gross margins to be in the range of 50%-51%, which is an increase from our previously issued range of 47%-49%. Turning to operating expenses. We now forecast expenses to be approximately $110 million.
As Reza mentioned previously, the majority of the incremental spend will be allocated towards expanding our commercial team and initiatives in the back half of 2022 to put us in a favorable position to execute on our long-term growth plan. Lastly, we continue to expect full-year adjusted EBITDA to be in the range of -$63 million to -$60 million, although we are trending more towards the high end of the range. At this point, I'd like to turn the call back to Reza for closing comments.
Thanks, Kevin. In closing, I want to thank our employees, customers, and shareholders for all their support to help us along our journey to becoming the center of care for BPH. We will continue to leverage our commercial and clinical investment to execute on our long-term strategy. Have a great day, and I look forward to meeting many of you at upcoming investor conferences. At this point, we will take questions. Operator?
As a reminder, to ask a question, please press star one one. Our first question comes from Joshua Jennings with Cowen. Your line is open.
Hi. Good afternoon. Thanks for taking the questions, and congratulations on another strong quarter. I was hoping to start with just ask about the raise of the revenue guidance range, and it suggests that sales funnel continues to fill against a backdrop of tightening capital budgets in the U.S., but hospital budgets. Can you talk about the sales pipeline for AquaBeam and how PROCEPT is navigating through this soft capital spending environment?
Yeah, thanks, Josh. We feel very good about our updated guidance and expect unit sales to increase sequentially in Q3 and Q4. Yes, there is some discussion about macro environment, but we are in a unique competitive position in the sense that we are early in our adoption curve, and there are a number of factors helping with adoption and utilization, and that starts with the clinical outcomes and real-world outcomes that physicians are seeing with our procedure. Hospitals and surgeons are using our procedure for all prostate size and shapes, and in fact, we are seeing in some hospitals standardization of the procedure. Also with the broad coverage, now we have full Medicare coverage. Many commercial payers are covering, and more importantly, patients are now seeking more durable, safe, and effective procedure.
All these factors are driving for better adoption and utilization. I think, Kevin, do you wanna add anything on utilization here?
Yeah, great. Josh, just to frame the guidance raise, you know, Reza gave a lot of background on the capital pipeline, but the high end of our guidance raise essentially is about a $3 million raise on capital and $3 million on handpiece. It's both penetration and utilization that's driving the increase in the revenue range.
Thanks for that. And just to follow up, wanted to ask about the proposed rule that you cited maintaining Aquablation procedures at a Level 6 APC code, and that's I think 3.5% tick up in reimbursement. I think everyone, you guys have been clear that the transitional pass-through payment is going away next year, but maybe you could help us understand relative to other resective procedures, you know, the profitability of this proposed level that CMS just issued. Then also just touch on the reimbursement premiums that Aquablation procedures are receiving from private payers. Thanks for taking the questions, guys.
Yeah. Thanks, Josh. So related to APC Level 6 , this was expected and we obtained the APC Level 6 and we believe our customer, we are confident they will be satisfied with APC Level 6. As far as the transitional pass-through is concerned, this is not new, it's not a surprise, and quite frankly, not a concern in the sense that transitional pass-through was transitional. If you look a year ago, we compare the coverage that we have today, compare where we are compared to last year, we have many private payers covering. That's on top of the Medicare. We believe that addition, based on our conversation with hospitals, these additions of this private payer outweighs the transitional pass-through going away. Again, this is an information that we have been communicating with all customers and they were aware, and we believe this is not a material issue.
Great. Thanks again.
Our next question comes from Craig Bijou with Bank of America. Your line is open.
Great. Thanks for taking the questions and congrats on another strong quarter. Wanted to ask first on utilization and maybe a little bit more about what you're seeing from individual doctors. Reza, I appreciate your comments that hospitals are. You're starting to see hospitals bring on new urologists to the system. Maybe if you can talk a little bit about the trends, the individual utilization trends once a urologist decides to adopt. You know, you guys have been in the market now for a number of quarters, so maybe you can touch on where their early adopters, where their utilization is now. Does it continue to grow within their own practice?
Yes. Thanks for this question. I mean, utilization increase is driven by multiple factors. As I mentioned, it starts with clinical outcomes. Physicians and surgeons and hospitals are using on a broad range of prostate. In fact, in the last 18 months, when we look at where the majority of these cases are done, it's on the prostate in the 60-80 ml range. They are using, again, on all prostate size and prostate shapes. In fact, they are standardizing resective procedure in many accounts to Aquablation. Some accounts have converted all their resective procedures to Aquablation. These are the driving factors for utilization. I don't know, Kevin, do you wanna add on. Definitely accounts which have been with us for many quarters, we see sequential growth of utilization, those accounts and Kevin can-
To Reza's point, I mean, we still recognize that the largest or highest utilized group are the customers that have been with us the longest. The utilization dynamic is still one that we're keeping a close eye on. It's important to remember that our install base is growing significantly. It grew roughly 40% in the first half of the year. By the time we get to the end of the year, we're gonna have an install base that is up 100% over the end of 2021. As we get additional cohort each quarter, Craig, we'll be able to provide more specificity around utilization metrics. For now, it's fair to say that our oldest customers have our highest utilization.
On top of that, we are also seeing, even in those customers that have been with us for multiple quarters, they're still adding new physicians to those accounts today, which is helping the utilization rate.
Got it. That's helpful, guys. On the sales reps, the adds that you expect in the second half, I'm not sure if I missed it or not, but did you say whether they were gonna be capital or Aquablation reps, maybe both? Maybe if you could go into a little bit of detail on the strategy for adding those reps. You guys have obviously been doing extremely well thus far. Maybe the strategy there, whether they're targeting certain geographies or you just need more feet on the street in current geographies.
Yeah, let me just, it's Kevin, let me start with the strategy. We've been very clear on this, that we would increase the size of our sales force when we felt it wouldn't jeopardize the excellent real world commercial outcomes that we expect. We're at that point now where we feel comfortable with our clinical data and commercial performance that we will increase the size of the field team. That, that's the strategy. In terms of the bifurcation, we're gonna continue to add at this time, probably a fairly equal number of both capital and Aquablation sales reps. We're nowhere near penetrated in every U.S. territory where we need to be. We have capital reps right now with some fairly large territories that we wanna take a look at.
My point being is we have a long runway in front of us in terms of adding commercial headcount to the business, and we'll continue to do that. The other point I wanna make on our reps is our guidance in the back half of 2022 doesn't imply really any meaningful contribution from these new folks. What we do wanna do, however, though, is make sure they get on board, we get them trained, they learn the protocol such that they could be productive as we enter 2023. Again, back to the strategy, we felt now is the right time given what we're seeing in the real world with both outcome, physician, and patient interest.
Great. Thanks for taking the questions, guys.
Thanks, Craig.
Our next question comes from Amit Hazan with Goldman Sachs. Your line is open.
Oh, thanks. Hey, good afternoon, guys. I wanted to maybe start with a couple of the macro questions that you've been on other earnings calls in the sector and just get your take on it. One is just on hospital staffing shortages and whether you all are seeing an impact from that at all that you would call out. Is it making it hard to get into do case observations, training done, installations, anything like that you would call out that's impactful to you?
Thanks, Amit, for the question. It has not impacted us. We are hearing that, but we have been able to achieve our forecast, so it has not been a material event for us.
Okay. I know kind of you're small and growing very fast, but do you have a sense of where we are in the BPH market overall in terms of just underlying market conditions as a percent of, you know, kind of where we were in 2019, the health of the BPH market, if you will, and how it's recovering? Maybe inside of that question, would just love to hear, you know, if you saw any change in trend during the quarter, whether, you know, procedures that same kinda high level I know for you they improve a lot 'cause you're growing. But overall procedures, did you get a sense that your customers saw improvement at all during the quarter and exiting into 3Q at a high level for the BPH segment?
Good question. Amit, this is Kevin. Look, we definitely believe that 2019 is the last, I would say, macro year that we can look at resective surgical numbers and consider that a normal operating environment. We would suggest that 2020 and 2021 were impacted by COVID. Therefore, frankly, we're not paying much attention to the procedures in those years. When I think about the macro environment, we're in a bit of a unique position that, as you mentioned, we're still at relatively low volumes. I mean, our current average utilization is around five and a half procedures per account per month. If you look at the customers we're targeting, on average, even in 2019, those customers were doing approximately 17 procedures a month.
We're still just very focused on increasing utilization with the accounts we've penetrated, which shields us a bit from some of the macro factors. Frankly, it's not terribly relevant to our growth in the near term if the market is growing 10% or decreasing 10%. I would definitely agree with you that 2020 and 2021 have been, on the macro level, impacted, but that hasn't really impacted our ability to grow.
Okay, just one last quick one for me is on the system side. Can you share how many systems that you sold were new accounts versus evals and if there were any retirements in the quarter?
No retirements, and we're now through the eval and demo pool. Moving forward, every new sale is a greenfield sale. We may periodically put a rental out with a customer, but right now our model is pretty much we're gonna sell, and not offer a demo program.
Okay. Thanks very much.
Our next question comes from Matthew Mishan with KeyBanc. Your line is open.
Hey, good afternoon, and thank you for taking the questions. Just first, it does seem like you're maintaining price as inflation goes, especially around the systems. Why would gross margin decline in the second half versus the first half of the year?
Yeah. It's a good question. Our guidance. By the way, welcome, Matt, it's your first call with us.
Yeah. Thank you.
Glad you're on board. If you look at our guidance, the high end of the margin range does imply approximately 50% gross margin in the back half of the year. You're recognizing that we just came off a Q2 where we recorded 51%. I'd point out a few things. The first being that we are still at relatively modest revenue levels, but gross margin percentages, they're going to fluctuate, and they can fluctuate fairly significantly on pretty low dollar volume. Just to put that in context. A $300,000 cost equates to a full 2 percentage points on margins. That relatively modest revenue with a high degree of fixed costs tends to have gross margin metrics that will be variable here in the near term, but trending in the right direction.
That'd be point one. Point two is we are increasing staffing levels in our operations group in anticipation of future growth. These are in areas like supply chain and production. This does create some additional expense. However, I would point out there's nothing unusual, there's nothing infrequent in our margins that's implied in our second half guidance. We still do believe that at scale, this business does have the potential for significant margin expansion over the long term. But there's gonna be some variability in the near term. There's nothing unusual, again, in the second half. It's a multitude of factors.
Okay. Excellent.
Unusual, again, in the second half. It's a multitude of factors.
Okay. Excellent. Just it does seem like you're controlling almost the pace at which you're installing these systems by, you know, the pace at which expanding your sales force. Just what makes you comfortable with a sales rep or a doctor or a system that you're placing this with that you're gonna get the outcome from that new placement you expect?
Yeah. This is just definitely we are very disciplined in targeting our accounts. We are in the U.S., those high volume hospitals that are doing on average more than 200 resective procedures per year. We are targeting those. Even before talking to the administrators in the hospital, we make sure we have a physician champion. Because of this disciplined approach, we have not seen pushback, and we have had high success rate in placing our robots. We are aware that we have expensive capital equipment, and this disciplined approach has allowed us to be successful, and that is the reason that you're talking.
Thank you very much.
Our next question comes from Neil Chatterji with B. Riley. Your line is open.
Hey, guys. Thanks for taking the questions. Just maybe circling back on the commercial team adds for the second half. Just, you know, wondering if you could just talk about kind of the expected like maybe quarterly cadence of that, if that's, you know, if you expect that to be weighted more towards third quarter or fourth quarter. Then if you could just maybe remind us on, you know, kind of the expected productivity ramp, you know. Is that, you know, before you start to see, you know, meaningful impact, is that, you know, three to six months or if you could just add some color there.
Yeah. By the way, welcome as well, Neil. I appreciate you covering the company now. In terms of cadence, I'll just talk about our OpEx spend of the $110 million. That does imply about a $60 million spend in the back half of the year. That expense cadence is relevant to how we're gonna build a sales team where the fourth quarter should be larger than the third quarter. Sequentially, Q3 should be up about $2 million-$3 million from Q2. That does suggest that, you know, the adds will be primarily mid to late Q3 by the time we have folks on board. That manifests itself in the OpEx expense guidance. That was on OpEx. What was your second question? Do you mind repeating?
I mean, I think that was.
The first-
That was pretty much it.
Oh, sorry. You asked about the productivity. Sorry.
Yes, exactly.
Generally, you know, it's three to six months for a rep to become fully productive. And again, that depends if you're going into new territories, which some of these reps will be doing, or if we'll be looking at perhaps splitting larger territories, which, you know, we may also have to do as we continue to grow. On average, it's a three to six-month ramp.
Got it. If I could just add a follow-up question here. Just kind of circling back on the international front. You talked about it, you know, last quarter with the Asia-Pacific, you know, regulatory approvals for Korea and Japan. Just kind of curious if there's any updates there in terms of adoption in Korea and kind of the reimbursement scenario in Japan. Secondly, you know, if you could talk about maybe your strategy for China and any expectations for the market there.
Yeah. Just in terms of... Well, I'll take each of those separately. In Korea, as mentioned on the last call, we expected very modest contribution in 2022. No, really no greater than $1 million is how I phrased that last quarter. We did sell another robot in Korea in the Q2, so that's in the number there. Again, continued penetration, but relatively modest revenue contributions moving forward. Japan, we're continuing to work through the reimbursement pathway there. We do not anticipate any Japan revenue in 2022. The next time we'll probably give a meaningful update on Japan would be when we introduce 2023 guidance. Flipping to China, we have started the regulatory process there, but that could be a fairly lengthy process. We are not expecting any meaningful contribution in China in the short term.
Great. That's it for me. Thanks.
There's no further questions at this time. I'd like to turn the call back over to Reza.
See you in the future. Thanks, everyone, for attending our earnings call. We look forward to seeing you in the future investment meetings. Have a nice day.
This concludes the program. You may now disconnect.