Long story short, to use H.323 behind a pfsense firewall, one needs to enable static-port NAT.
Unfortunately neither H.323 nor SIP were designed with NAT in mind, in which case one needs either an ALG (which btw is part of Linux's netfilter since many years, but apparently missing from baseline pf/FreeBSD) or a NAT device that won't rewrite ports (a solution that will work if you only have one such device).
Edit: Note that SIP software has been improved in recent years, and most recent implementations can work through NAT without a need for ALG or static ports, but it's still something one has to keep in mind when troubleshooting SIP issues.