Ancient Rome, using advancements not seen again until the nineteenth century, was renowned as a civilization not only with central heating, flush toilets, and a sophisticated plumbing system, but also as an advocate of artistic and musical endeavors.
Not only x...but also y, where x and y must be parallel.
A. as a civilization not only with central heating, flush toilets, and a sophisticated plumbing system, but - X and y are not parallel
B. as a civilization that not only used central heating, flush toilets, and a sophisticated plumbing system, and - Incorrect idiom, ...not only...and also.....
C. not only as a civilization with central heating, flush toilets, and a sophisticated plumbing system, but - x and y are parallel. not only as a civilization with A, B and C ,but also as an M and N. Not only as a noun + preoposition + noun...., but also as an noun...
D. not only as a civilization using central heating, flush toilets, and a sophisticated plumbing system, but - usage of using does not maintain parallelism and changes the meaning as using modifies to civilization, how can civilization use A, B and C?? People of civilization can use A, B and C. (Hope NandishSS may get your answer)
E. not only as a civilization with central heating, flush toilets, and a sophisticated plumbing system, and - Incorrect idiom, ...not only...and also.....
Imo. C