I was able to get audio working again, but cannot understand why this would have fixed it.

While the game was running at the Title Screen.
Under System -> Sound -> Speakers
My format was at to 24bit, 19.2KHz (Studio Quality)
I changed it 16bit, 19.2KHz (Studio Quality) and started to hear audio.

I quit the game and changed it back to 24bit, 19.2KHz (Studio Quality).
Launched the game again, expecting the same issue but nope, audio is working again.

I had changed this setting before, but never while the game was running.