Great question, I think the answer falls into 2 specific models - but the gist is that it's linked to the number of VM CPU Cores and not the number of SQL Server Instances.
- Standard IaaS PAYG billing.
The per-second cost of running the Azure VM includes the cost of the SQL Server license. The per-second licensing cost depends on the number of VM vCPUs.
It's important to size the VM correctly as you'll pay per CPU, so even if you had multiple instance of SQL on the VM they all share the same CPUs.
You can run multiple instances on the VM, as the VM covers the license.
https://learn.microsoft.com/en-us/azure/azure-sql/virtual-machines/windows/pricing-guidance?view=azuresql#pay-per-usage - Hybrid HYB licensing
Allows using existing SQL Server core licenses with Software Assurance in an Azure VM.
Again, it's licensed on the CPU (cores), and it is reliant on you paying for Software Assurance. "You must have a license for SQL Server Standard or Enterprise and Software Assurance, which is a required option through some volume licensing programs and an optional purchase with others"