As the docs confirmed to Allure, E! does pay patients who appear on the show, and they can use that money towards their surgeries. In the real world, the procedures featured on Botched are exceedingly expensive. 

Speaking with The Cheat Sheet the doctors laid it all out. "We do extraordinarily difficult, as you know, high-risk visual plastic surgery, which is more costly in general because the risks are greater," Dr. Dubrow explained, noting the considerable length of time each surgery takes, too. The longest surgery on the show took eight hours total, according to Dr. Nassif, but Dubrow questioned keeping a patient under anesthetic for that amount of time.